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MRS.  PRUDENCE  W.  KOFOID 


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DIPHTHERIA: 


ITS  NATURE  AND  TREATMENT, 


AN  ACCOUNT  OF  THE  HISTORY  OF  ITS  PREVALENCE 
IN  VARIOUS  COUNTRIES. 


BY 


DANIEL   D.    SLADE,    M.  D. 


BEING  A  SECOND  AND  REVISED  EDITION  OF  AN  ESSAY  TO  WHICH 
WAS  AWARDED  THE  FISKE  FUND  PRIZE  OF  1S60. 


PHILADELPHIA: 

BLANCHARD    AND    LEA. 

1864. 


The  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting  of  the  Rhode 
Island  Medical  Society,  held  ia  Newport,  July  11,  1860,  announced  that  the 
premium  of  one  hundred  dollars  offered  by  them  on  the  subject  of '"Diph- 
theria, its  nature  and  treatment,  with  an  account  of  the  history  of  its  pre- 
valence in  different  countries,"  had  been  awarded  to  the  author  of  the 
dissertation  bearing  the  motto — 

"  Felix  qui  2^01  uit  rerum  cognoscere  causa s.'''' 

And  upon  breaking  the  seal  of  the  accompanying  packet,  they  learned  that 
the  successful  competitor  was  Daniel  Denison  Slade,  M.  D.,  of  Boston,  Mass. 
James  H.  Eldridge,  M.  D.,  East  Greenwich, 
Charles  W.  Parsons,  M.  D.,  Providence, 
Henry  E.  Turner,  M.  D.,  Newport, 

Trustees. 
S.  Aug.  Arnold,  M.D.,  Providence,  Secretary  of  the  Fiske  Fund. 


Pnil.ADKLPHlA  : 
COLLINS,    1'  lU  N  T  E  R  . 


O  .-b  .3 


buP 


-^ 


^^xX-*^ 


PREFACE. 

5 


The  publication  of  another  edition  of  this  essay 

has  afforded  an  opportunity  for  its  thorough  re- 

visal,  and   for  such  additions   as  experience   and 

observation  have  taught  us.     Our  knowledge  of 

the  nature,  causes,  and  treatment  of  diphtheria  is 

still  lamentably  deficient,  and  it  is  only  by  the 

\      most  diligent  study,  and  by  the  most  careful  ob- 

j.       servation,  that  we  may  hope  to  arrive  hereafter  at 

'^o  more  satisfactory  results. 


Boston,  October,  1864. 


^ 


P^i352839 


DIPHTHERIA 


No  diseases  of  late  years  have  awakened  more  atten- 
tion, both  among  the  profession  and  the  public  gene- 
rally, than  those  which  have  been  classed,  more  or  less 
correctly,  under  the  term  diphtheritic.  ISTor  is  this  to  be 
wondered  at  when  we  consider  the  distressing  nature  of 
the  symptoms,  and  the  terrible  fatality  with  which  the 
epideitpics  of  malignant  sore  throat  have  so  often  been 
attended. 

Diphtheria  is  a  synonyme  of  the  word  Diphtherite,^ 
originally  used  by  M.  Bretonneau  in  his  treatise  on  this 
subject,  which  appeared  in  1826,  and  which  is  chiefly 
made  up  of  his  own  observations  on  the  epidemics  of 
malignant  sore  throat  prevailing  at  Tours  and  in  its 
neighborhood  in  1818,  and  again  in  1825  and  1826. 

The  following  are  the  specific  characters  of  diphtherite, 
according  to  M.  Bretonneau  : — ^ 

At  the  commencement  of  the  disease  a  circumscribed 

'  Ai<p^Bpa  and  At<j>'^£f£?  liave  botli  the  same  signification,  the  pre- 
pared slvin  of  an  animal ;  Ai<p9ipirn<:  and  Ai<i>6s^U(;  botli  signify  that 
which  is  covered  with  skin. 

2  Traite  de  la  Diphtherite,  Paris,  1826,  p.  49. 
9 


14  DIPHTHERIA. 

redness  is  seen,  covered  with  a  semitransparent  coagu- 
lated mucus.  This  first  layer,  which  is  slight,  supple, 
and  porous,  may  be  still  further  raised  up  by  portions 
of  unaltered  mucus,  in  such  a  manner  as  to  form  vesicles. 
Frequently  the  red  spots  perceptibly  extend  from  one  to 
another,  either  by  continuity  or  by  contact,  like  a  liquid 
which  is  spread  out  upon  a  flat  surface,  or  which  runs 
by  streaks  in  a  tube.  The  concretion  becomes  opaque, 
white,  and  thick,  and  assumes  a  membranous  consistence. 
In  this  stage  it  is  easily  detached,  and  does  not  adhere 
to  the  mucous  membrane,  except  by  some  very  delicate 
prolongations  of  concrete  matter  which  penetrate  into 
the  muciparous  follicles.  The  surface  which  it  covers  is 
usually  of  a  fliint  red  tint,  with  points  of  a  deeper  red ; 
this  tint  is  brighter  at  the  periphery  of  the  spots. 

If  the  false  membrane,  in  detaching  itself,  leaves  the 
mucous  surface  uncovered,  the  redness  which  the  exuda- 
tion has  concealed  returns,  and  the  points  of  a  deeper 
red  allow  blood  to  transude.  The  exudation  is  renewed 
and  becomes  more  and  more  adherent  at  the  points 
which  were  first  attacked ;  it  often  acquires  a  thickness 
of  several  lines,  and  passes  from  a  yellowish-white  to  a 
l)rown-gray  or  black  color.  At  the  same  time  the 
transudation  of  blood  becomes  still  more  free,  and  is  the 
source  of  those  stillicidia  which  have  been  so  generally 
noted  by  authors.  At  this  time  the  alteration  of  the 
organic  surfaces  is  more  apparent  than  at  the  beginning ; 
often  portions  of  concrete  matter  are  effused  into  the 
very  substance  of  the  mucous  tissue.     A  slight  erosion 


SPECIFIC    CHARACTERS.  15 

and  sometimes  even  eccbymoses  are  observed  at  those 
points  which,  by  their  situation,  are  exposed  to  friction, 
or  from  which  the  avulsion  of  the  false  eschars  has  been 
attempted.  It  is  especially  just  at  this  period  that  the 
pellicles  which  are  undergoing  decomposition  give  out  a 
foul  odor.  If  they  are  circumscribed,  the  oedematous 
swelling  of  the  surrounding  cellular  tissue  makes  them 
appear  depressed,  and  from  this  appearance  alone  we 
might  be  led  to  believe  that  we  had  before  us  a  foul 
ulcer  with  a  considerable  loss  of  substance.  If,  on  the 
contrary,  they  are  extended  over  large  surfaces,  they  are 
partly  detached,  hang  in  shreds  more  or  less  decom- 
posed, and  simulate  the  appearance  of  the  last  stages  of 
sphacelus.  But  when  we  open  the  bodies  of  those  who, 
after  some  days  of  sickness,  die  of  tracheal  diphtherite, 
we  shall  find  in  the  air-passages  all  the  gradations  of 
this  inflammation  from  its  first  stage  on  the  portions 
recently  attacked,  up  to  that  which  by  the  aspect  of  a 
gangrenous  alteration  at  the  points  which  were  first 
afiected,  is  most  likely  to  deceive  us. 

Diphtheria,  according  to  M.  Bretonneau,  is  a  specific 
disease.  Its  specific  character  consists,  anatomically,  in 
the  formation  of  a  false  membrane  of  definite  structure 
— pathologically,  in  the  power  of  reproducing  itself. 
"  Nothing  is  diphtheria  that  has  not  a  pellicular  exuda- 
tion; no  such  exudation  is  diphtherical  which  is  not 
capable  of  acting  as  a  virus  or  contagion." 

These  were  the  views  expressed  in  the  treatise  of  M. 


16  DIPHTHERIA. 

Bretonneau,  and  to  these  be  still  adheres,  with  some 
modifications,  in  a  paper  published  in  the  Archives 
Generales  de  Mklecine,  1855. 

Under  the  term  diphtheria,  Bretonneau,  however,  has 
connected  several  affections,  which  in  the  prevailing 
nosology  are  separated  from  each  other  by  wide  inter- 
vals. This  point  will  demand  of  us  especial  considera- 
tion. 

How  far  his  description  of  diphtheria  is  to  be  con- 
sidered a  faithful  representation,  how  far  it  is  to  be  taken 
as  a  universal  type  of  the  disease,  are  questions  to  be 
answered  only  by  a  careful  comparison  of  the  accounts 
of  the  epidemics  of  "  sore  throat"  or  "  angina"  w^hich 
have  invaded  various  portions  of  the  world,  at  longer  or 
shorter  intervals,  particularly  during  the  last  two  centu- 
ries. On  making  such  comparison  it  will  be  found  that 
they  exhibit  marked  differences  in  their  characteristic 
symptoms  and  dangers,  having  been  frequently  regarded 
as  different  diseases.  We  shall,  however,  not  only  be 
satisfied  of  their  identit}^,  a  fact  so  well  established  by 
Bretonneau,  but  also  of  the  common  character  by  wdiich 
this  identity  may  be  recognized,  viz.,  the  existence  of 
the  exudation  of  false  membrane. 

As  regards  the  special  virulence  of  the  diphtheritic 
exudation  which  constitutes  an  important  feature  in  M. 
Bretonneau's  views  of  diphtheria,  it  will  be  seen,  as  we 
proceed,  that  so  far  from  inoculation  being  the  only 
mode  of  propagation,  there  is  no  suiTicient  reason  to 
suppose  that  a  concrete  virus  exists;  that  epidemics  of  a 


HISTORY.  17 

rapidly  fatal  character  have  occurred,  where  the  exuda- 
tion has  been  extremely  liimted  and  where  death  has 
been  brought  about  solely  by  the  constitutional  disturb- 
ance. 

History. — We  can  undoubtedly  trace  back  the  history 
of  this  affection  to  a  period  almost  contemporary  with 
Homer.  Whether  such  be  the  case  or  not,  certain  it  is 
that,  ten  centuries  later,  we  find  distinct  descriptions  of  a 
form  of  malignant  sore  throat  in  the  writings  of  Aretseus, 
under  the  name  of  Egyptian  or  Syrian  ulcer.  This 
prevailed  in  the  two  countries,  more  especially  among 
children.  It  was  characterized  by  the  appearance  of 
•ulceration  in  the  throat,  by  fetid  breath,  and  sometimes 
by  great  dyspnoea. 

Macrobius  speaks  of  a  similar  epidemic  at  Eome,  A.D. 
880,  during  which  sacrifices  were  offered  up  to  a  certain 
Goddess — "ut  populus  Eomanus,  morbo,  qui  angina 
dicitur,  promisso  voto,  sit  liberatus." 

A  fatal  epidemic  of  sore  throat  occurred  in  Holland, 
in  1337.  Hecker,^  in  his  account  of  the  "  Sweating 
sickness"  of  England,  in  1517,  says  that — 

"In  January  of  that  year,  there  appeared  in  Holland 
another  disease  whfbh,  from  its  dangerous  and  inexpli- 
cable symptoms,  spread  fear  and  horror  around.  It 
was  a  malignant  and  infectious  inflammation  of  the 
throat,  so  rapid  in  its  course  that,  unless  assistance  was 
procured  within  eight  hours,  the  patient  was  past  all 

•  Hecker's  Epidemics,  p.  224. 

2^ 


18  DirUTHERIA. 

Lope  of  recovery  before  the  close  of  the  day.  Sudden 
pains  in  the  throat,  and  violent  oppression  of  the  chest, 
especially  in  the  region  of  the  heart,  threatened  suffoca- 
tion, and  at  length  actually  produced  it.  During  the 
paroxysms  the  muscles  of  the  throat  and  chest  were 
seized  with  violent  spasms,  and  there  were  but  short 
intervals  of  alleviation,  before  a  repetition  of  such 
seizures  terminated  in  death.  Unattended  by  any  pre- 
monitory symptoms,  the  disease  began  with  a  severe 
catarrhal  affection  of  the  chest,  which  speedily  advanced 
to  inflammation  of  the  air-passages. 

"  The  physicians  had  recourse  to  venesection  and  pur- 
gatives. Moreover,  the  employment  of  detergent  gargles, 
whereby  the  extension  of  the  affection  to  the  lungs  was 
prevented,  as  also  of  demulcent  pectoral  remedies,  was 
decidedly  beneficial.  .  .  Most  of  those  affected  were 
taken  ill  at  the  same  time;  and  eleven  days  of  suffering 
and  misery  had  scarcely  elapsed,  when  not  another  case 
occurred.  It  spread,  however,  no  doubt,  beyond  Hol- 
land, for  in  the  same  year  we  find  it  in  Basle,  where, 
within  eight  months,  it  destroyed  about  2000  people, 
and  its  symptoms  would  seem  to  have  been  more 
strongly  marked. 

"Eespecting  the  intermediate  countries,  which  it  is 
highly  probable  that  the  disease  passed  through  from 
Holland  before  it  reached  Basle,  we  unfortunately  have 
no  information.  The  tongue  and  gullet  were  white,  as 
if  covered  with  mould ;  the  patient  had  an  aversion  to 
food    and    drink,    and    suffered   from    malignant   fever, 


niSTORY.  19 

accompanied  witti  continued  headache  and  deliriam. 
Here,  in  addition  to  an  internal  method  of  cure  not  de- 
tailed, the  cleansing  of  the  mouth  was  perceived  to  be 
an  essential  part  of  the  treatment ;  the  viscous  white 
coating  was  removed  every  two  hours,  and  the  tongue 
and  fauces  were  afterwards  smeared  with  honej^  of 
roses." 

In  1557,  a  similar  epidemic  appeared  in  Holland, 
which  proved  very  fatal,  and  Vvdiich  spread  to  other  parts 
of  Europe.  It  has  been  described  by  M.  Forest.  He 
says  :— 

"It  was  not  so  rapid  in  its  course  as  in  1517,  but 
began  with  a  slight  fever,  like  a  common  catarrh,  and 
showed  its  great  malignity  only  by  degrees.  Sudden 
fits  of  suffocation  then  came  on,  and  the  pain  of  the 
chest  was  so  distressing  that  the  patients  imagined  that 
they  must  die  in  the  paroxysm.  The  complaint  was 
increased  still  more  by  a  tight  convulsive  cough.  Death 
did  not  take  place  till  the  ninth  or  fourteenth  day.  The 
painful  affection  of  the  stomach  was,  in  this  epidemic, 
very  distinctly  marked,  so  that  a  sense  of  pressure  at  the 
precordia,  accompanied  by  continued  acid  eructations, 
continued  to  exist  even  after  a  succession  of  six  or  seven 
fits  of  fever ;  and  convalescents  were  troubled  with  dys- 
pepsia, debility,  and  hypochondriasis." 

In  1576,  there  was  a  very  malignant  form  of  throat 
disease  prevalent  in  Paris.  In  fact,  from  the  end  of  the 
16th  century,  we  find  that  epidemics  of  angina  have 
shown  themselves  almost  constantly  to  a  greater  or  less 


20  DIPHTHERIA. 

extent,  in  some  portions  of  the  old  or  new  world.  In 
the  beginning  of  the  17th  century,  an  epidemic  of  angina 
occurred  in  Spain,  which  received  the  name  of  ''Garo- 
tillo,"  because  those  who  were  attacked  by  it  perished  as 
if  strangled  by  a  cord.  This  has  been  described  by 
Mercatus,  Yillareal,  Nunez,  and  by  others.  In  1618,  the 
same  disease  appeared  at  Naples,  which  the  inhabitants 
termed  "  male  de  canna,"  disease  of  the  trachea.  It  raged 
here  to  a  greater  or  less  extent  for  twenty  years,  and  has 
been  described  by  several  writers,  among  whom  we  may 
mention  Nola,  Carnevale,  Syambati,  Zacutus  Lusitanus, 
and  Marcus  Aurelius  Severinus.  Carnevale,  in  par- 
ticular, has  given  us  full  data  of  this  epidemic  in  his 
treatise  entitled,  "De  Epidemico  Strangulatione  Affectu." 
The  children  were  first  attacked,  the  disease  afterwards 
spreading  among  the  population  generally,  and  proving 
very  fatal.  The  disease  commenced  by  a  mild  inflam- 
mation of  the  throat;  soon  the  affected  parts  presented 
a  whitish  exudation;  the  breath  became  fetid;  degluti- 
tion impossible;  the  respiration  embarrassed,  and  the 
patient  died  of  suffocation.  This  writer  also  gives  us 
the  different  appearances  which  the  pharynx  presented 
in  this  epidemic ;  he  also  speaks  of  the  extension  of  the 
disease  to  the  trachea,  oesophagus,  pituitary  membrane — 
of  the  diagnosis,  prognosis,  and  the  topical  remedies,  all 
of  which  are  quite  in  accordance  with  modern  views. 

In  1632,  Alaymus  published  a  treatise  upon  "Syrian 
Ulcers."  He  prefers  this  term,  he  says,  inasmuch  as  it 
applies  to  all  forms  of  the  disease,  which  he  describes  in 


HISTOKY.  21 

a  similar  manner  with  Carnevale.  No  writer  of  this 
age,  however,  speaks  of  cutaneous  diphtheria  in  connec- 
tion with  the  other  sj^mptoms  which  thej  describe, 
although  most  of  them  particularly  notice  the  extension 
of  the  disease  to  the  air-passages. 

From  the  middle  of  the  seventeenth  century  up  to 
1740,  we  find  but  little  mention  made  of  the  prevalence 
of  malignant  angina.  But  very  shortly  after  this,  in 
1743,  the  disease  made  its  appearance  in  Paris,  where  it 
prevailed  until  1748,  and  has  been  described  by  Malouin 
and  Chomel.  At  about  the  same  time  a  similar 
epidemic  appeared  both  in  England  and  at  Cremona, 
accounts  of  wdiich  are  recorded  by  Fothergill,  Starr,  and 
Ghisi. 

In  England  these  epidemics  proved  very  destructive. 
The  epidemic  described  by  Fothergilh  is,  without  doubt, 
closely  allied  with  scarlatina.      He  says  : — 

"It  generally  comes  on  with  giddiness  and  chills,  which 
are  soon  followed  by  great  heat ;  these  states  alternate 
for  a  few  hours,  until,  at  length,  the  heat  becomes 
constant  and  intense.  Then  follows  acute  pain  in  the 
head,  heat  and  soreness,  rather  than  pain  of  throat, 
stiffness  of  the  neck,  commonly  great  sickness  or 
purging,  or  the  two  combined.  The  face  soon  after 
looks  red  and  swelled,  the  eyes  inflamed  and  watery,  as 
in  measles,  restlessness,  anxiety  and  faintness.  If  the 
mouth  and  throat  be  examined  soon  after  the  first  attack, 

'  Account  of  tlie  Sore  Throat,  attended  with  Ulcers.  London,  1748. 


22  DIPnTHERIA. 

the  uvula  and  tonsils  are  found  swelled ;  and  these  parts 
together  with  the  velum  palati  and  pharynx  appear  of  a 
florid  red  color,  which  is  most  marked  on  posterior  edge 
of  palate  in  the  angles  above  the  tonsils,  and  upon  the 
tonsils  themselves.  Instead  of  redness,  a  broad  spot  or 
patch  of  an  irregular  form  and  of  pale  white,  is 
sometimes  seen  surrounded  with  florid  red,  which  white- 
ness appears  like  that  of  the  gums  immediately  after 
being  pressed  with  the  fingers,  or  as  if  matter  ready  to 
be  discharged  was  contained  beneath.  Generally  on 
the  second  day  of  the  disease,  the  face,  neck,  breast  and 
hands,  are  of  a  deep  erysipelatous  color,  with  a 
sensible  tumefaction.  A  great  number  of  small  pimples 
of  a  color  more  intense  than  that  which  surrounds  them 
appear  on  the  arms  and  other  parts.  (In  a  note,  he  says, 
the  eruption  and  redness  have  not  so  regularly  ac- 
companied the  disease  during  the  latter  part  of  this 
winter,  1754,  as  they  did  last  year.  In  some  cases  they 
did  not  appear  at  all,  in  others  not  till  the  third  or 
fourth  day.) 

"  The  appearances  in  the  fauces  continue  the  same, 
except  that  the  white  places  become  more  ash-colored  ; 
and  it  is  now  found  that  what  might  be  taken  for  the 
superficial  covering  of  a  suppurated  tumor  is  really  a 
slough  concealing  an  ulcer.  Instead  of  the  slough  in 
mild  cases,  a  superficial  ulcer  of  an  irregular  form  ap- 
pears in  one  or  more  parts,  scarce  to  be  distinguished 
from  the  sound,  but  by  the  irregularity  of  surface  which 
it    occasions.     Towards    ni2;ht     heat    and    restlessness 


HISTORY.  23 

increase,  and  a  peculiar  kind  of  delirium  frequently 
comes  on.  The  pulse  is  generally  very  quick ;  in  some, 
hard  and  small ;  in  some,  soft  and  full.  The  tongue  is 
generally  moist,  and  not  often  found.  In  some  it  is 
covered  with  a  thick  white  fur ;  and  these  generally  com- 
plain of  soreness  about  the  root  of  the  tongue." 

Fothergill  also  speaks  of  an  acrid  discharge  from  the 
nose,  and  remarks  that  there  was  sometimes  epistaxis  at 
the  commencement  of  the  attack.  He  describes  faint- 
ness  as  a  common  symptom,  also  diarrhoea  at  the  outset. 
He  is  very  positive  about  the  separation  of  sloughs 
which  leave  ulcers.  Although  he  does  not  mention 
dropsy  as  a  sequela,  3^et  he  evidently  had  entertained  the 
notion  of  the  disease  beins^  allied  to  scarlatina ;  but,  he 
remarks,  it  differed  from  the  sore  throat  and  scarlet 
fever  described  in  Edinburgh  in  1733. 

Ghisi,  after  having  given  a  detailed  description  of  the 
epidemic  of  sore  throat  which  commenced  at  Cremona 
in  1747,  remarks  that  the  disease  proved  fatal  by  suffoca- 
tion, even  in  those  cases  where  the  attention  of  the 
patient  had  not  been  called  to  the  condition  of  the 
throat.  This  absence  of  difficulty  in  deglutition  has 
been  constantly  observed,  however,  according  to  M. 
Bretonneau,  in  all  the  epidemics  of  malignant  angina, 
particularly  in  those  of  Tours.  Ghisi  describes  cases 
which  appear  to  be  primary  and  not  secondary  to  scarla- 
tina. He  especially  indicates  the  peculiarity  of  the 
pseudo-membranous  concretion  which  lines  the  air- 
passages. 


24  DIPHTHERIA. 

In  1747;  M.  Arnault,  of  Orleans,  mentions  cases  of 
malignant  sore  throat  which  carried  off  the  patient  in 
twenty-four  hours.  At  the  autopsies  of  two  children 
dead  from  this  disease  the  mucous  membrane  of  the 
trachea  was  found  detached  to  the  extent  of  several 
inches.  It  was  of  the  consistence  of  parchment,  and  of  a 
white  color. 

In  1708,  ^NTartcau  de  Grandvilliers  published  descrip- 
tions of  cases  of  gangrenous  angina,  which  he  had 
observed  for  many  years  in  Picardy.  These  observa- 
tions, according  to  M.  Bretonneau,  would  have  con- 
tributed essentially  towards  a  right  understanding  of  the 
several  mooted  points,  had  not  the  writer  confounded 
scarlatinal  with  diphtheritic  angina. 

Iluxham^  describes  an  epidemic  in  1757,  prevailing 
in  England,  which  was  also  closely  allied  with  scarlatina. 
He  says : — 

"  Most  commonly  the  angina  came  on  before  the  cx- 
anthem,  but  many  times  the  eruption  appeared  before 
the  sore  throat,  and  was  sometimes  very  considerable, 
though  there  was  little  or  no  pain  in  the  fauces ;  on  the 
contrary,  a  very  severe  angina  seized  some  patients  that 
had  no  manner  of  eruption  ;  and  yet  even  in  these  cases 
a  very  great  itching  and  desquamation  sometimes 
ensued,  but  this  w^as  chiefly  in  grown  persons,  very 
rarely  in  children." 

'  nuxlinin,  I'is.scrt:iUoii  on  the  Malignant  Ulcerous  Sure  Throat. 
London,  1707. 


HISTORY.  25 

The  eruption  was  sometimes  pustular,  sometimes 
erysipelatous.  He  alludes  to  some  cases  in  which  there 
were  signs  of  croup,  but  the  symptoms  were  not  well 
marked ;  the  peculiar  breathing  and  suffocation  were 
wanting.  He  remarks  that  "in  all  sorts  of  fevers  about 
this  time  there  was  a  surprising  disposition  to  eruptions 
of  some  kind  or  other,  to  soreness  of  throat,  and  apncea." 
His  attention  was  chiefly  directed  to  the  condition  of  the 
fauces,  and  he  does  not  at  all  seem  to  appreciate  the 
tendency  of  the  disease  to  extend  to  the  air-passages. 
Yet,  by  his  own  statements,  some  of  his  cases  must  have 
terminated  with  laryngeal  symptoms. 

"Not  only,"  says  he,  "were  the  nostrils,  fauces,  &c., 
affected,  but  the  windpipe  itself  was  much  corroded,  and 
pieces  of  its  internal  membrane  were  spit  up." 

Dr.  Starr,  of  Liskeard,  published  a  paper  in  the 
Philosophical  Transactions,  upon  the  malignant  ulcerous 
sore  throat  epidemic  which  appeared  in  that  place  in 
1749.  In  this  paper,  besides  other  details  of  the 
epidemic,  he  gives  the  full  data  of  a  case  in  which  the 
false  membrane,  commencing  in  the  fauces,  extended  to 
the  larynx.  He  particularly  dwells  upon  the  physical 
properties  of  the  exudation,  its  adherence  to  the  sub- 
jacent surface,  its  frequent  detachment  and  reproduction. 
In  fact,  he  gives  a  complete  picture  of  Bretonneau's 
diphtheria. 

In  1761,  Kosen  gives  an  account  of  an  epidemic  which 
prevailed  in  Sweden. 
3 


26  DIPHTHERIA. 

Dr.  Samuel  Bard'  published  a  dissertation  upon  the 
nature,  causes,  and  treatment  of  suffocative  angina,  as  it 
appeared  in  New  York  in  1771.  To  this  writer  we  shall 
have  occasion  to  revert  more  particularly  when  we  come 
to  trace  the  history  of  diphtheria  in  our  own  country. 

From  this  period  the  disease  and  the  writings  which 
the  subject  had  called  forth,  seem  to  have  been  laid 
aside,  and  almost  lost  sight  of,  when,  in  1826,  the 
treatise  of  Bretonneau  made  its  appearance.  This  we 
may  truly  consider  the  first  connected  and  practical 
research  upon  the  nature  of  the  affection.  Of  late,  the 
disease  has  become  firmly  established  in  France,  and  it 
■would  seem,  judging  from  the  experience  of  the  last  few 
years,  that  it  has  also  prevailed,  to  a  greater  or  less 
extent,  in  England  and  in  our  own  land.  It  has  been 
described  by  many  French  writers,  among  whom  we 
may  mention  Guersant,  Isambert,  Chomel,  Andral, 
Itilliet,  Barthez,  Trousseau,  and  Bouchut. 

It  is  by  a  careful  study  of  the  most  characteristic  and 
important  researches  into  these  epidemics  that  we  are 
enabled  to  gain  at  least  a  partial  insight  into  the  nature 
of  the  disease,  and  to  contrast  the  present  with  the 
earlier  accounts  of  its  character. 

The  epidemic  at  Tours,  in  1818—1821,  so  vividly 
described  by  Bretonneau,  first  broke  out  in  the  barracks, 
amongst  the  soldiers,  and  thence  spread  to  the  surround- 
ing quarters.     Among  the  military  the  gums  were  the 

'  Rosearclies  on  the  Nature,  Causes,  and  Treatment  of  Suflbcative 
Angina,  &c.     By  Satuuel  Bard,  M.  D,     New  York. 


niSTORY.  27 

portions  most  frequently  attacked,  the  air-passages  being 
rarely  affected.  As  it  spread  into  the  city,  the  larynx, 
however,  was  the  portion  which  the  disease  selected, 
wdiile  the  gums  were  unaffected;  children  being,  in  most 
cases,  the  victims. 

Those  who  were  thus  attacked  rarely  complained 
much  at  the  outset  of  the  attack,  although  deglutition 
was  slightly  interfered  with.  On  examination  of  the 
throat  it  was  found  to  be  somewhat  inflamed ;  shortly  a 
yellow-grayish  patch  could  be  seen  upon  the  tonsils, 
which  spread  rapidly  over  the  soft  palate,  the  mouth, 
and  the  pharynx ;  the  cervical  and  submaxillary  glands 
became  swollen  and  inflamed.  The  outward  appearance 
of  the  patient,  the  leaden  aspect,  the  dulness  of  the  eye, 
the  uncertain  step,  bore  evidence  of  the  severe  character 
of  the  disease,  while  the  hoarseness  of  the  cough,  the 
change  in  the  tone  of  the  voice,  the  extremely  fetid 
breath,  and  the  grayish-black  exudation  upon  the 
pharjmx,  were  speedily  followed  by  suffocating  dyspnoea 
and  death. 

From  Tours  the  epidemic  spread  to  two  small  hamlets. 
La  Fevriere  and  Chanusson,  to  which  places  it  was  for  a 
time  confined. 

"From  this  time  it  continued  to  traverse  the  depart- 
ments of  France,  passing  mainly  from  the  southern 
littoral  districts  towards  the  centre.  It  did  not  seem 
possible    to    ascribe    its   visitations    to    any    particular 

'  See  cases  reported  by  Bretonneau  in  his  Treatise,  1826. 


28  DIPHTHERIA. 

climate  or  meteorological  conditions ;  for  historical 
documents  show  that  while  it  raged  with  terrible 
violence  amongst  the  towns  and  hamlets  of  the  Loiret, 
remarkable  for  their  salubrity  and  the  advantages  of 
their  geographical  position,  it  passed  over  the  villages  of 
Sologne,  seated  amidst  marshes;  while  elsewhere  it 
seemed  to  select  marshy  and  ill-drained  districts,  and  to 
spare  those  which  were  in  a  better  sanitary  condition. 
Again,  while  in  the  year  1825,  a  year  remarkable  for  its 
extreme  dryness,  the  communes  north  of  Orleans  were 
laid  waste  by  diphtheria,  it  made  as  many  victims  in  the 
damp  and  warm  year  1828,  in  the  country  south  of 
Orleans.'" 

In  this  year  Trousseau  saw  thirteen  out  of  seventeen 
individuals  die  in  the  same  farm-house,  all  attacked  with 
diphtheria. 

In  181:1  an  epidemic  occurred  in  the  Children's 
Hospital  at  Paris,  which  has  been  described  by  M. 
Becquerel.^  In  this  many  of  the  children  were  attacked 
with  sore  throat,  sometimes  false  membranes  being  pro- 
duced, and  at  others  sloughs  and  gangrene,  the  one 
running  into  the  other.  The  pharynx,  larjnix,  and 
blistered  surfaces  were  the  parts  attacked.  In  all  the 
cases  tliere  was  a  want  of  coagulability  in  the  blood,  and 
pulmonary  apoplexy  often  accompanied  the  malady. 

In  the  Archives  Gentrales  de  Medecine,  M.  Empis' 
gives  a  most  valuable  paper  upon  an  epidemic  of  diph- 

'  Report  of  the  Lancet  Sanitary  Commission,  1859. 

«  Gazette  Medicale  de  Paris,  1843.  ^  March,  1850. 


HISTORY.  29 

theria  whicTi  occurred  at  the  Hopital  JSTachez,  in  18-i8. 
Both  the  mucous  and  cutaneous  surfaces  were  attacked, 
in  many  cases  conjointly. 

There  was  a  very  virulent  epidemic  in  Paris  in  1855, 
attacking  the  rich  and  poor  indiscriminately ;  carrying 
off  adults,  but  expending  itself  more  particularly  upon 
children. 

From  the  early  part  of  1855  to  March,  1857,  a  serious 
epidemic  prevailed  in  Boulogne,  during  which  366 
persons  died,  of  whom  many  were  English.  A  greater 
portion  of  those  who  were  carried  off  were  under  ten 
years  of  age. 

M.  Lemoine  has  described  an  epidemic  at  Nievre,  in 
which  the  air-passages  generally  escaped. 

In  the  department  of  the  Haute  Marne,  the  diphtheria 
had  a  decided  predilection  for  the  nasal  fossce,  the 
larynx,  for  the  most  part,  escaping.  This  epidemic  was 
described  by  M.  Jobert.  M.  Lespiau  has  given  an 
account  of  an  epidemic  which  occurred  among  the 
military  at  Avignon,  in  the  autumn  of  1853,  and  in 
which  the  false  membrane  usually  spread  to  the  air- 
passages.  Of  1796  soldiers,  195  were  attacked;  and  of 
22  children  belonging  to  one  regiment,  4  suffered.  In 
the  cases  secondary  to  other  diseases  nearly  all  died, 
while  in  the  primary  cases  only  6  per  cent.  died. 

Such  is  a  concise  history  of  the  epidemics  of  malig- 
nant angina  which  have  been  observed  in  Europe,  and 
more  especially  in  France,  during  the  present  century. 
Before  giving  an  account  of  the  history  of  diphtheria  in 

3* 


80  DIPHTHERIA.    * 

England,  let  us  compare  more  closely  the  experience  of 
FrencTi  practitioners  during  the  epidemics  of  the  last 
few  years  with  the  observations  of  Bretonneau.  AYe 
shall  confine  ourselves  to  a  few  of  the  most  important 
points. 

In  his  Tmite  de  la  Diphtherlte,  Bretonneau  says 
little  of  the  constitutional  symptoms  which  accompany 
diphtheria,  probably  because  he  did  not  attribute  to 
them  anything  more  than  a  secondary  importance. 
He  says : — 

"At  the  onset  of  diphtheria,  the  organic  functions  and 
those  which  belong  to  the  life  of  relation,  are  so  little 
disturbed  that  children  who  are  already  dangerously 
affected   by    malignant   angina,    generally    retain    their 

habitual  appetite,  and  continue  their  play 

The  disease  only  becomes  mortal  when  the  membranous 
layers  which  line  the  interior  of  the  air-passages,  form, 
by  their  accumulation,  or  by  their  adherence,  a  mechani- 
cal obstacle  to  respiration If  a  topical  treat- 
ment modifies  the  diphtheritic  inflammation,  the  return 
to  health  follows  immediately  on  the  cessation  of  the 
local  disease.'" 

In  a  recent  paper  in  the  Archives  Genemles  de  Mede- 
cine,  to  which  we  have  before  alluded,  Bretonneau  has 
somewhat  modified  his  idea  that  diphtheria  is  essentially 
a  local  disease.  In  the  recent  epidemics  in  France,  the 
disease   has   come    on    insidiously,    and    hastened   to   a 

'  Addition  suppleuieutairo  au  Traite  do  la  Uiplitherite. 


NATURE.  31 

fatal  termination  in  a  manner  not  to  be  explained  by 
such  a  theory.  Still  maintaining  the  opinion  that  the 
constitutional  state  of  diphtheria  is  secondarj^  and 
incapable  of  existing  independently  of  the  local  changes, 
he  assumes  that  whenever  the  disease  takes  on  a  sud- 
denly fatal  form,  whenever  the  constitutional  seem  to 
precede  the  local  symptoms,  an  explanation  is  to  be 
found  "not  in  the  antecedence  of  a  morbid  diathesis,  but 
in  the  secret  development  of  diphtheria  in  the  nostrils." 
And  this  assumption  seems  to  be  founded  solely  upon 
the  fact  that  in  some  cases  coryza  and  glandular  swell- 
ings have  preceded  the  graver  symptoms. 

Although  we  cannot  by  any  means  agree  with  the 
distinguished  observer  in  views  which  are  so  much  at 
variance  with  modern  experience,  we  must  do  him  the 
justice  to  say  that  the  characters  of  the  disease,  as 
observed  by  him  in  1826,  were  undoubtedly  as  he  has 
described  them,  but  that,  during  the  last  few  years, 
the  disease  has  assumed  new  forms  and  been  attended 
with  new  dangers.  Trousseau  has  most  distinctly 
admitted  this  change  of  type  of  diphtheria,  in  the 
Gazette  des  Hopitaux,  1855  : — 

"  There  is  a  form  of  diphtheria  to  which,  for  seven  or 
eight  years  past,  innumerable  victims  have  succumbed, 
which  differs  so  completely  from  all  others  in  the 
general  aspect  of  its  symptoms,  that  one  would  be 
tempted  to  establish  a  line  of  demarcation;  but  in  direct- 
ing our  attention  to  its  mode  of  invasion  and  etiology, 
we   have   no  difl&culty  in   recognizing   conformity  and 


82  DIPHTHERIA. 

even  identity ;  tLe  difference  being  that  the  diphtheritic 
disease  assumes  a  character  of  exceptional  gravity,  and 
kills  at  once  by  the  constitutional  affection  without  the 
participation  of  the  larynx.  Usually  the  sore  throat 
seems  to  be  the  first  symptom ;  but  sometimes  it  is  pre- 
ceded by  a  coryza  of  great  severity,  as  if  the  pituitary 
membrane  had  been  attacked  before  the  fauces." 

*' There  is  also  swelling  of  the  lymphatic  ganglia  of 
the  neck,  which  is  sometimes  so  enormous  as  to  extend 
beyond  the  jaw. 

"  Join  to  this  acute  pain  in  the  head,  extremely  intense 
fever  (excessive  frequency  of  the  pulse),  and  you  will 
have  the  signs  of  the  onset  of  the  worst  forms  of  diph- 
theria. Some  hours  after  you  will  observe  false  mem- 
brane on  the  uvula  and  velum ;  the  dischargee  from  the 
nose  becomes  fetid,  and  if  you  open  the  nares  with  an 
ear  speculum,  false  membranes  are  observed  on  the 
septum  and  turbinated  bones.  The  patient  does  not 
sleep,  and  is  in  a  state  of  extreme  agitation ;  the 
breathing  is  stertorous  and  snoring 

"After  thirty-six  or  forty-eight  hours,  the  features 
assume  a  livid  pallor,  delirium  follows,  and  the  unfortu- 
nate patient  dies  with  all  the  appearance  of  amemia,  and 
in  a  state  of  somnolent  tranquillity  which  strongly  con- 
trasts with  the  agitation  that  distinguishes  the  agony  of 
croup.  It  is  impossible  to  describe  the  horrible  prostra- 
tion, the  powerless  exhaustion,  the  frequent  faintings, 
in  one  of  which  the  thread  of  life  is  often  severed." 

Again,  in   the   course   of  a    report   read    before   the 


NATURE.  33 

Imperial  Academy  of  Medicine,  on  the  2d  ISTovember, 
1851,  M.  Trousseau  makes  tlie  followinor  remarks: — • 

"  Those  of  us  who  for  twenty -five  years  have  followed 
the  epidemics  of  diphtheria  which  have  stricken  the 
capital,  may  satisfy  ourselves  that  the  disease  has  not 
only  extended  itself  considerably,  particularly  during 
the  last  twelve  or  thirteen  years,  but  has  assumed  a 
much  graver  form.  Up  to  about  1846,  diphtheria 
scarcely  appeared  in  the  epidemic  form,  and  the  cases  of 
it  which  were  observed  in  Paris  presented  all  the 
characters  so  well  described  by  Bretonneau  in  his 
treatise,  and  so  clearly  pointed  out  by  Guersant  in  the 
Dktionnaire  de  Mtidecine,  where  this  excellent  practitioner 
confirms  in  every  particular  what  the  illustrious  physi- 
cian of  Tours  had  seen 

"The  diphtherite  described  by  Bretonneau  generally 
commenced  in  the  pharynx,  and  there  remained  the 
longer  in  proportion  to  the  youth  of  the  child,  giving 
rise  usually  to  but  little  fever,  scarcely  in  any  way 
affecting  the  rest  of  the  economy,  and  was  propagated 
to  the  larynx,  thus  constituting  croup.  But  within  the 
last  ten  years,  in  place  of  this  affection,  comparatively  of 
little  severity,  there  has  appeared  another,  in  which 
hitherto  all  the  resources  of  art  have  been  nearly  un- 
availing. 

"The  pharynx,  it  is  true,  is  most  commonly  first 
attacked,  but  in  a  little  time  the  disease  extends  to  the 
nares,  to  the  nasal  duct,  and  sometimes  to  the  internal 
surface  of  the  eyelids ;    and   at   the   same   time  ataxo- 


34  DIPHTHERIA. 

adynamic  symptoms  become  manifest,  the  pulse  becomes 
very  frequent,  the  cervical  glands  greatly  enlarge,  and 
frequently  forty-eight  hours  after  the  attack,  the  patient 
dies,  iviihout  the  larynx  having  heen  sufficiently  affected  to 
suggest  the  idea  of  croiij).  It  seems  as  though  a  poison 
had  been  introduced  into  the  system,  by  which  the 
latter  had  been  intimately  and  rapidly  modified." 

So  also  in  the  account  given  by  M.  Isambert'  of  the 
epidemic  in  Paris  in  1856,  we  find,  under  the  head  of 
malignant  diphtheritic  angina,  the  following  observa- 
tions : — 

"We  retain  the  old  name  of  malignant  an2:ina  to 
designate  that  specific  form  in  which  the  patient  suc- 
cumbs to  a  profound  adynamia,  to  a  general  intoxica- 
tion, and  in  nowise  to  the  occlusion  of  the  larynx.  For 
in  cases  of  this  description  tracheotomy  not  only  does 
not  save,  but  it  does  not  even  temporarily  relieve  the 
patient.  This  form  of  angina  seems  to  have  escaped  the 
notice  of  M.  Bretonneau,  and  as  we  cannot  suppose  that 
a  man  of  his  powers  of  observation  could  overlook  a 
type  of  the  disease  so  well  marked,  we  must  admit  that 
it  did  not  present  itself  in  those  epidemics,  in  the  midst 
of  which  the  eminent  physician  wrote  his  Traite  de  la 
Di/phtherite.  This  form,  then,  appears  to  be  a  new  one, 
although  without  doubt  it  is  to  this  that  many  of  the 
descriptions  of  the  malignant  or  gangrenous  anginas  of 
the  early  epidemics  apply." 

'  Ar.;li.  Gen.  de  Meaecine,  1857. 


NATURE.  85 

Having  described  the  anatomical  lesions,  tlie  enormous 
tumefaction  of  the  cervical  glands,  and  the  other  local 
changes,  he  goes  on  to  say  : — 

"These  local  disorders,  so  grave  in  character,  are 
accompanied  by  a  general  state  not  less  serious :  burn- 
ing fever,  extreme  restlessness,  insupportable  headache, 
depriving  the  patient  of  all  sleep,  are  present;  shortly 
tv^phoid  symptoms,  the  most  complete  adynamia,  declare 
themselves;  the  fever  appears  to  diminish  towards  the 
end,  the  pulse  becomes  small,  and  the  patient  falls  into 
a  condition  of  somnolent  tranquillity,  which  announces 
the  termination." 

Were  it  necessary,  in  order  to  prove  that  the  constitu- 
tional symptoms  of  diphtheria  have  not  only  been  pre- 
sent, but  have  often  assumed  a  primary  importance 
during  the  epidemics  of  the  last  few  years,  we  might 
refer  to  many  other  papers  published  by  French  practi- 
tioners. We  shall  have  occasion  to  observe  the  import- 
ance of  these  symptoms  when  we  study  the  historj^  of 
the  English  epidemics. 

One  of  the  points  most  particularly  insisted  upon  by 
M.  Bretonneau  is  the  absence  of  all  relation  between 
diphtheria  and  gangrene  of  the  fauces.  He  even  con- 
siders it  characteristic  of  the  affection  that  the  mucous 
membrane  remains  unaltered  throughout.  He  says  that 
malignant  angina  is  unaccompanied  with  any  sloughing, 
and  a  contrary  opinion  could  only  arise  from  deceptive 
appearances,  for  in  none  of  the  cases  at  Tours,  even 
w^hen  malignant  angina  had  assumed  the  most  repulsive 


36  DIPHTHERIA. 

aspect,  could  anything  be  discovered  which  resembled  a 
gangrenous  lesion. 

In  this  opinion  he  certainly  seems  to  be  supported  by 
historical  testimony,  especially  as  regards  some  of  the 
epidemics  of  the  last  century. 

"The  results  of  the  analysis  of  historical  testimony  do 
not  differ  in  any  respect  from  those  which  my  own 
direct  observations  furnish  me."* 

But  in  others  of  the  recent  French  epidemics,  in 
which  researches  were  conducted  with  a  special  view  to 
a  solution  of  this  point,  gangrene  has  occurred  as  the 
expected  termination  of  all  the  most  malignant  cases, 
and  not  as  a  mere  accident.  In  the  epidemic  at  Paris  in 
1841,  described  by  M.  Becquerel,  and  to  which  we  have 
already  referred,  gangrenous  sore  throat  prevailed  at  the 
same  time  wdth  cases  which  presented  the  true  char- 
acters of  diphtheria.  The  two  forms  of  disease  were  not 
to  be  distinguished  as  respects  their  origin,  the  local 
affection  not  being  preceded  by  any  constitutional 
symptoms.  The  fauces,  too,  in  all  cases,  at  first  pre- 
sented appearances  purely  diphtheritic.  In  those  which 
in  their  progress  took  on  the  gangrenous  aspect,  the 
exudation  became  friable,  and  soon  separated  from  the 
mucous  surface.  At  first  this  was  usually  entire,  but 
exhibited  the  appearance  of  a  limited  eschar,  and,  on 
being  thrown  off,  left  a  deep  excavation.  The  constitu- 
tional symptoms  preceding  death  were  the  same  as  those 

'  Traite  de  la  Diphlherite,  p.  13. 


NATURE.  87 

wliich  usually  accompany  gangrene — diminution  of  tern" 
perature,  a  rapid  and  almost  imperceptible  pulse,  great 
restlessness,  frequent  vomiting,  involuntary  stoolS;  &;c. 
These  cases  were  generally  fatal. 

From  the  fact  that  many  of  these  cases  were  examined 
after  death,  there  is  no  reason  to  suppose  that  there 
could  be  any  mistake  as  to  the  actual  presence  of  gan- 
grene. In  15  cases  examined,  there  was  gangrene  affect- 
ing the  tonsils  exclusively  in  9,  and  in  the  remaining  6, 
the  pillars  of  the  velum  and  pharynx.  In  the  tonsil,  the 
gangrene  was  either  in  the  centre  or  near  the  surface. 
In  either  case,  the  resulting  cavity  was  irregular  in  form, 
filled  with  a  thin  fetid  fluid,  and  was  surrounded  by 
softening  of  the  submucous  tissue,  which  was  to  a 
greater  or  less  extent  converted  into  greenish-gray 
detritus.  The  disintegration  evidently  commenced  be- 
neath the  mucous  membrane,  which,  at  first  merely 
swollen  and  rugose,  gradually  took  on  a  gangrenous 
appearance  and  color,  and  finally  terminated  in  an 
eschar.  AYhen  this  separated,  the  cavity  was  left 
exposed. 

The  history  of  this  epidemic  clearly  shows  that 
although  the  gangrenous  form  of  diphtheria  differs  from 
the  purely  membranous  in  various  ways,  yet  it  occurs 
under  the  same  epidemic  influence. 

M.  Isambert,  in  his  account  of  the  Paris  epidemics  of 
1855  and  '56,  distinguishes  both  forms  of  diphtheria,  the 
one  tending  to  a  fatal  result  by  extension  to  the  larynx, 
4 


38  DIPHTHERIA. 

the  other,  wliicli  lie  calls  angina  maligna  diphtheritica, 
assuming  a  totally  different  character. 

"  It  is  particularly  to  this  form,"  he  says,  "  that  are  to 
be  referred  those  confluent  exudations  of  a  dirty  gray  or 
black  color,  giving  out  a  gangrenous  odor.  .  .  .  Several 
times  we  have  observed  undoubted  loss  of  substance 
beneath  the  exudation."^ 

Again : — 

"In  this  disease  the  membranous  exudation,  soon 
after  its  appearance,  softens,  and  assumes  a  dirty  gray 
or  blackish  color,  the  uncovered  mucous  surface  is  livid, 
the  adenetic  swelling  is  enormous,  and  affects  not  only 
the  glands  themselves,  but  the  cellular  tissue,  the  skin 
often  sloughing  from  extensive  tension." 

Death  is  preceded  by  gradually  increasing  prostra- 
tion, but  not  accompanied  by  any  nervous  symptoms 
more  marked  than  those  described  by  M.  Becquerel  in 
the  account  of  his  epidemic. 

M.  Duche  gives  a  description  of  the  diphtherite  which 
has  proved  so  fatal  for  the  last  few  years  in  the  depart- 
ment of  L'Yonne. 

"The  principal  features  of  this  epidemic  (1858)  are 
cephalalgia,  fever  more  or  less  intense,  and  pain  in  the 
fauces.  Upon  examining  the  mouth,  the  tonsils  are 
found  swollen  and  red,  and  on  the  surface  of  one — some- 
times on  both  at  the  same  time — there  is  a  white  patch 
of  variable  dimensions.     These  patches  quickly  enlarge, 

•  Archives  Generales,  1857. 


NATURE.  89 

reacli  tlie  velum  palati  and  uvula,  wliicli  latter,  at  times, 
becomes  enormously  enlarged ;  later,  they  invade  the 
posterior  wall  of  the  pharynx,  and  descend  gradually 
into  the  larynx  and  bronchia,  and  even  into  the  oesopha- 
gus and  digestive  organs. 

"The  first  period,  which  may  be  called  pharyngeal,  is 
characterized  by  a  painful  sensation,  and  the  ejection 
from  the  mouth  of  abundant  sputa,  mixed  with  blood 
and  false  membrane.  The  invasion  of  the  larynx  is 
marked  by  all  the  signs  of  croup,  and  asphyxia  rapidly 
terminates  the  scene  of  agony.  On  the  contrary,  when 
the  larynx  escapes,  there  is  an  apparent  calm,  which  de- 
ceives the  most  experienced  eyes.  Then  there  is  a  little 
vomiting  of  glairy  matter,  great  thirst,  absence  of  pain, 
but,  soon  complete  prostration ;  pulse  insensible ;  absence 
of  urine  during  four  or  five  days,  and  death  by  syncope. 

"It  is  generally  easy,  by  aid  of  curved  forceps,  to 
seize  and  tear  away  the  membranous  exudations,  when 
they  cover  only  the  tonsils,  uvula,  or  pharynx.  The 
mucous  membrane,  thus  denuded,  is  livid  and  bloody ; 
and  in  spite  of  the  most  energetic  cauterizations,  a  few 
hours  suffice  for  the  reappearance  of  new  morbid  forma- 
tions like  the  first.  Gangrene  of  the  pharynx  often 
terminates  the  disease  in  a  sudden  manner,  and  we  are 
warned  of  this  fatal  issue  by  the  fetor  of  the  breath,  and 
of  substances  ejected  from  the  mouth." 

According  to  Bretonneau,  diphtheria  also  includes 
croup.  He  says :  "  Croup  is  but  the  extreme  degree  of 
malignant  angina."     Now,  it  would  certainly  seem  very 


40  DIPHTHERIA. 

evident,  to  those  of  us  who  have  derived  our  ideas  of 
the  word  croup  from  Dr.  Francis  Home's  description  of 
this  affection/  or  from  the  graphic  lecture  on  Cynanche 
trachealis,  by  Dr.  Watson,  that  Bretonneau  uses  the 
word  in  a  very  different  sense. 

It  is  well  known  that  Dr.  Home  first  introduced  the 
term  croup  into  medical  literature  in  1765,  and  to  him 
is  due  the  honor  of  first  defining  the  characters  of  a  dis- 
ease which  had  been  in  part  described  by  the  most  an- 
cient authors.  He  first  drew  attention  to  the  fact,  that 
the  formation  of  a  false  membrane  in  the  trachea  and 
larynx  is  essential  to  the  disease,  and  constitutes  the 
source  of  danger. 

Dr.  Home's  description  of  croup  was  not  only  accepted 
by  most  of  the  physicians  of  England,  but  also  by  many 
in  Europe.  His  views  were  especially  supported  by  the 
writings  of  Cheyne,  Cullen,  and  others,  but  still  more 
particularly  by  the  report  of  the  commissioners  of  the 
famous  concours  instituted  by  Napoleon.  The  ideas  of 
these  writers  were,  in  brief — 

"That  croup  is  an  acute  inflammation  of  the  mucous 
membrane  of  the  air-passages,  distinguished  from  others 
by  the  rapidity  of  its  progress ;  by  the  existence  of  con- 
crete exudation  in  the  larynx,  and  by  the  fact  that  it 
principally  attacks  children  under  ten  years  of  age. 
They  regard  cold  and  moisture  as  its  main  causes,  and 
support  this  inference  by  all   that  is  known  as  to  the 

'  Inquiry  into  the  Nature,  Cause,  and  Cure  of  the  Croup — Ediuboro', 
1765. 


NATURE.  41 

seasons  during  wliich  the  disease  is  most  apt  to  occnr; 
and  the  climates  in  which  it  is  most  prevalent ;  and  they 
hold  that  it  is  its  habit,  to  select  for  its  invasion,  single 
individuals  in  large  populations,  without  communicating 
itself  to  the  rest — in  other  words,  that  it  is  apt  to  be 
sporadic,  not  epidemic." 

Dr.  Watson,  in  his  lectures,  says : — 

"  Some  analogy  with  that  disease  (croup)  it  certainly 
has,  but  the  points  of  difference  are  stronger  and  more 
essential.  It  resembles  croup,  inasmuch  as  it  leads  to 
the  production  of  an  adventitious  membrane  upon  a 
mucous  surface.  It  differs  in  the  position  of  that  mem- 
brane, which  is  seldom  formed  in  the  trachea.  The 
affection  of  the  windpipe,  when  it  occurs  at  all,  is  second- 
ary, so  that  the  term  ^cynanche  trachealis'  would  be 
quite  inappropriate." 

In  an  admirable  lecture  on  Diphtheria,  by  Dr. 
Eanking,  and  published  in  the  Lancet,^  we  find  the 
following  remarks : — 

"The  great  distinctive  m.ark  between  diphtherite  and 
croup,  properly  so  called,  is  to  be  found  in  the  locality 
chiefly  affected.  In  both,  it  is  true,  a  main  feature  is  the 
presence  of  an  exudation ;  bat  in  the  one  disease,  it 
commences  in  the  fauces,  and  only  reaches  the  windpipe 
by  extension,  and  in  a  certain  number  of  cases ;  in  the 
other,  that  of  true  croup :  it  commences  in  the  larynx 
and  trachea,  and  does  not  necessarily  affect  the  soft  parts 
above  the   glottis  at  all.     As  a  consequence  of  this,  a 

1  The  Lancet,  Jau.  15,  1859. 


42  DIPHTHERIA. 

marked  difference  is  also  found  in  the  symptoms  of  the 
two  diseases.  In  diphtheria  the  uneasiness  is  first  re- 
ferred to  the  parts  subservient  to  deglutition;  in  croup^ 
on  the  contrary,  the  earliest  symptom  is  that  of  stridu- 
lous  voice  and  breathing — a  symptom  which,  in  the 
former,  indicates  the  final  development  of  diseased 
action." 

Dr.  Hauner,^  director  of  the  children's  hospital  at 
Munich,  concludes  a  paper  upon  this  subject  with  the 
following  aphorisms  : — 

"1.  True  croup  (laryngeal  croup)  is  a  disease  proper 
to  childhood,  and  its  cause  is  chiefly  to  be  sought  in  the 
organization  (the  period  of  development)  of  the  hirynx 
at  this  period  of  life.  2.  The  anatomy  and  physiology 
of  the  larynx  sufficiently  explain  the  nature  of  croup. 
3.  It  cannot  be  shown  that  croup  is  connected  with  any 
peculiarity  of  the  blood  crasis.  4.  True  croup  always 
commences  in  the  larynx,  and  often  passes  downwards 
to  the  trachea,  kc,  but  it  never  passes  upwards.  5. 
Laryngeal  croup  is  characterized  by  a  pseudo-membrane 
of  more  or  less  extent.  6.  Laryngeal  croup  is  to  be 
carefully  distinguished  from  diphtheritic  croup,  the 
latter  alwa3^s  depending  upon  a  peculiar  blood  crasis,  as 
seen  in  other  organs  of  enfeebled  individuals.  7. 
Diphtheritic  croup  is  almost  always  secondary,  and  is 
not  essentially  different  from  croup  in  an  after  acute 
exanthemata,  8.  The  diphtheritic  form  begins,  as  a 
general   rule,   in    the   fauces,    uvula,   tonsils,    &;c.,    and 

'  Journal  fur  Kinderkrankheiten. 


NATURE.  43 

extends   hence   downwards.     It   is  very  rare  for   it   to 
commence  in  the  larynx  or  trachea,  &c." 

It  is  well  known  that  Dr.  West,  in  his  work  upon  dis- 
eases of  children,  has  considered  diphtheritis  as  a  form 
of  croup.  In  the  last  edition  of  his  work,  however,  he 
has  seen  fit  to  modify  his  previous  views.  In  speaking 
of  croup  and  diphtheria,  he  says : — 

"Of  these  two  diseases,  the  one  is  almost  always 
idiopathic,  the  other  is  often  secondary  ;  the  one  attacks 
persons  in  perfect  health,  is  sthenic  in  its  character, 
acute  in  its  course,  and  usually  proves  amenable  to 
antiphlogistic  treatment.  The  other  attacks  by  prefer- 
ence those  who  are  out  of  health,  or  who  are  surrounded 
by  unfavorable  hygienic  conditions,  and  is  remarkable 
for  the  asthenic  character  of  the  symptoms  which  attend 
it.  The  one  selects  its  victims  almost  exclusively  from 
among  children ;  is  incapable  of  being  diffused  by 
contagion ;  is  governed  in  its  prevalence  by  influence  of 
season,  temperature,  and  climate,  but  rarely  becomes,  in 
the  usual  acceptation  of  the  term,  an  epidemic.  While 
the  other  attacks  adults  as  well  as  children,  is  propagated 
by  contagion,  and,  though  it  occasionally  occurs  in  a 
sporadic  form,  is  susceptible  of  wide-spread  epidemic 
influence. 

.  .  .  .  "Different,  however,  as  are  the  two  dis- 
eases, there  are  yet  between  them  points  of  similarity  no 
less  strikino:,  and  the  diasrnostic  difficulties  are  still 
further  enhanced  by  the  occasional  simultaneous  preva- 
lence of  both  affections. 


44  DIPHTHERIA. 

....  "It  has,  indeed,  been  suggested  by  M.  Isam- 
bert,  in  a  recent  valuable  paper,  that  the  condition  of 
the  subjacent  mucous  membrane  furnisbes  a  ground  of 
distinction  between  the  affections;  and  that  while  in 
diphtheria  the  surface  beneath  the  exudation  is  often 
ulcerated,  no  such  erosion  of  the  mucous  membrane  is 
met  with  in  true  croup.  This  is  not,  however,  accord- 
ing to  my  observation,  for  ulceration  of  the  mucous 
membrane  has  come  under  my  notice  in  primary  croup, 
though  less  frequently  than  in  cases  of  the  diphtheritic 
kind. 

"Whatever  differences  exist  between  croup  and  diph- 
theria, must  be  sought  elsewhere  than  in  the  patho- 
logical changes  observable  in  the  respiratory  organs ; 
and  the  affinities  of  the  latter  disease  are  seen  to  be  to 
the  class  of  blood  diseases,  rather  than  to  that  of  purely 
local  inflammation  to  which  croup  belongs." 

With  Bretonneau,  nearly  all  French  writers  regard 
croup  and  diphtheria  as  identical.  In  justification  of 
this  view,  so  little  consonant  with  our  own  ideas,  we 
may  remark  that  in  France,  true  croup  is  commonly 
introduced  by  a  diphtheritic  affection  of  the  fauces,  and 
that  sometimes  it  appears  to  be  contagious,  which  is  not 
considered  to  be  true  of  the  sporadic  disease  as  observed 
in  England  and  in  our  country.  ^loreover,  in  France, 
it  differs  by  its  asthenic  character,  and  to  some  extent 
by  the  nature  of  the  exudation,  which  is  less  tenacious. 

In  fine,  the  laryngeal  diphtheritis  of  Bretonneau,  and 
of  other   French  authors,  although    closely  resembling 


NATURE.  45 

the  disease  described  by  Home,  and  known  to  us  as 
croup  in  its  anatomical  cliaracters,  differs  widely  in  its 
dynamical  ones.  Moreover,  it  is  contagious  and  epi- 
demic. 

Bretonneau  lias  also  in  a  measure  confounded  scarla- 
tina with  diphtheria  under  the  term  "  Scarlatina  Angi- 
nosa." 

The  exact  relation  which  exists  between  these  two 
diseases  has  been  a  much  debated  question.  By  some 
persons  the  two  affections,  notwithstanding  certain 
points  of  strong  resemblance,  are  regarded  as  essentially 
different.  By  others,  diphtheria  is  looked  upon  as  a 
form  of  scarlet  fever,  in  which  the  throat  affection  is 
unaccompanied  by  the  eruption  w^hich  usually  charac- 
terizes it. 

We  must  admit  that  there  are  many  circumstances 
which  favor  this  latter  opinion.  For  instance,  not  only 
do  the  two  diseases  prevail  frequently  at  the  same  time 
in  the  same  region,  but  even  in  the  same  family ;  some 
members  being  attacked  by  all  the  symptoms  of  true 
diphtheria,  while  others  present  the  symptoms  of 
common  scarlatina.  Then,  again,  in  some  instances, 
in  those  who  have  been  attacked  by  diphtheria,  a  rash 
very  similar  to  that  of  scarlatina  has  been  observed. 
This  rash  may  have  been  very  partial,  and  may  have 
remained  but  a  few  hours,  but  its  characters  have  been 
thought  sufficiently  marked  to  leave  no  douhit  as  to  its 
nature.  Moreover,  since  the  albuminous  condition  of 
the  urine  has  been  so  frequently  observed  in  cases  of 


46  DIPHTHERIA. 

diplitberia,  it  may  be  tLonght  that  the  analogy  between 
the  two  diseases  is  drawn  still  closer. 

These  facts  are  certainly  of  great  weight,  but  we  shall 
see  that  there  are  other  considerations  still  stronger 
which  may  be  adduced  in  favor  of  the  essential  differ- 
ence between  the  two  diseases.  For  example,  as  regards 
the  existence  of  a  rash.  This  has  certainly  been  occa- 
sionally noticed  in  some  epidemics  of  diphtheria,  but  in 
the  great  majority  it  has  not  been  observed  at  all. 
Whereas,  in  epidemics  of  scarlet  fever  its  absence  is  a 
rare  exception,  and  occurs  only  in  those  cases  of  very 
malignant  character  which  are  marked  by  great  cerebral 
disturbance,  violent  delirium,  and  by  speedy  death. 
In  diphtheria,  on  the  other  hand,  the  intellect  remains 
undisturbed  until  the  very  last. 

Then,  again,  the  rash  is  in  many  respects  dissimilar 
from  that  seen  in  scarlatina.  It  is  described  as  being 
for  the  most  part,  of  a  uniform  erythematous  redness, 
without  the  peculiar  punctated  appearance  of  the  scarlet 
fever  rash,  appearing  suddenly  in  patches,  not  deepening 
in  intensity  gradually,  and  not  followed  by  any  change 
in  the  other  symptoms,  nor  by  any  increase  in  their 
severity. 

As  to  the  presence  of  albumen  in  the  urine,  there  are 
certain  points  to  be  especially  observed.  When  present 
there  is  no  diminution  in  the  quantity  of  the  secretion, 
neither  is  frhere  any  other  particular  change  in  its  charac- 
ter. Moreover,  the  albumen  seems  often  to  disappear  at 
a  very  early  period  of  the  disease. 


NATURE.  47 

"Its  disappearance  takes  place  suddenly,  and  thougli 
its  presence  is  usually  observed  in  cases  where  this  dis- 
ease is  severe,  yet  there  does  not  seem  to  be  any  neces- 
sary connection  between  the  urine  becoming  non- 
albuminous,  and  the  disease  assuming  a  milder  type." 

Again,  the  sequelae  of  the  two  diseases  are  widely 
different.  For  while,  on  the  one  hand,  we  have  none  of 
the  formidable  dropsical  symptoms  in  the  convalescence 
of  diphtheria,  which  so  often  succeed  scarlatina,  on  the 
other,  we  do  have  a  peculiar  loss  of  nervous  power,  and 
temporary  muscular  paralysis  which  have  no  analogy 
to  anything  in  the  sequelae  of  the  latter  disease. 

Dr.  GreenhoW;  in  his  excellent  monograph^  on  this 
disease,  says : — 

"Besides  the  absence  after  diphtheria  of  the  well 
known  sequelae  of  scarlet  fever,  the  former  disease  is 
succeeded  by  sequelae  of  a  character  peculiar  to  itself, 
and  such  as  have  not  been  found  to  follow  scarlet  fever. 
These  are  partial  paralysis  of  the  muscles  of  deglutition 
and  voice,  impairment  or  disorder  of  vision,  paraplegia, 
hemiplegia,  partial  paralysis  of  the  upper  extremities, 
numbness  of  the  hands  or  feet,  tenderness,  pricking  or 
tingling  of  the  extremities,  and  gastrodjmia.  Then, 
lastly,  the  occurrence  of  diphtheria  on  other  parts  of  the 
body,  as  on  abrasions  of  the  skin  or  wounds,  or  on  the 
pudenda,  has  no  parallel  in  scarlet  fever.  When  to 
these  differences  we  add  that  the  anaemia  which  soon 

>  On  Diphtheria,  by  Edw.  Headlam  Greenhow,  M.  D.,  F.  R.  C.  P. 
N.Y.,1861. 


48  DIPHTHERIA. 

occurs,  and  for  a  long  time  succeeds  to  diplitberia,  is 
more  intense  than  in  almost  any  other  acute  disease, 
there  can  be  little  hesitation  in  accepting  the  conclusion 
that  diphtheria  and  scarlet  fever  are  not  the  same  disease." 

Lastly,  almost  universal  experience  bears  testimony  to 
this  fact,  viz.,  that  diphtheria  does  not  protect  from 
scarlet  fever,  nor,  on  the  other  hand,  does  scarlet  fever 
prove  any  defence  against  diphtheria.  Of  this  the 
following  may  serve  as  examples : — 

"Three  children  in  a  family  in  my  district  (Islington) 
were  attacked  with  diphtheria  in  August,  1858.  Two 
of  them  died ;  the  third,  aged  three  years,  recovered.  I 
saw  these  children,  and  satisfied  myself  that  there  was 
no  error  in  the  diagnosis.  In  January,  1859,  the  child 
that  recovered  was  attacked  with  scarlet  fever,  after 
playing  about  upon  a  carpet  brought  from  a  house 
where  a  fatal  case  of  this  disease  had  occurred.  There 
was  both  the  rash,  and  the  usual  throat  affection,  but  no 
diphtheritic  exudation ;  and  the  child  died."^ 

Dr.  West  gives  the  following  case  :  — 

"In  a  school  in  the  neighborhood  of  London,  diph- 
theria broke  out ;  many  of  the  lads  w^ere  affected  by  it, 
and  one  or  two  died.  Several  of  those  who  were  conva- 
lescent from  the  disease  were  sent  to  the  sea  coast  for 
the  more  speedy  recovery  of  their  strength,  and  while 
there  some  were  attacked  by  scarlet  fever,  and  this  also, 
in  one  or  two  cases,  proved  fLital."'^ 

1  Dr.  Eclw.  Ballard,  Med.  Times  and  Gazette,  July  23,1859. 

2  Dr.  West,  Diseases  of  Childhood,  1S50. 


HISTORY.  49 

Dr.  Greenhow  states  that,  at  the  outset  of  his  in- 
quiries, he  was  inclined  to  doubt  that  diphtheria  was 
entirely  distinct  from  scarlatina.  But  careful  observa- 
tion aud  more  ample  experience  have  satisfied  him  that 
notwithstanding  their  frequent  occurrence  in  the  same 
place,  and  their  occasional  coincidence  in  the  same 
individual,  diphtheria  and  scarlatina  are  distinct  dis- 
eases. 

Numerous  cases  similar  to  these  might  be  cited. 
And,  although  further  and  more  accurate  observations 
may  hereafter  tend  to  a  different  conclusion,  we  are 
decidedly  of  the  opinion  that  the  balance  of  evidence  at 
the  present  time  is  in  favor  of  the  non-identity  of  scarla- 
tina and  diphtheria. 

As  regards  the  history  of  the  earlier  epidemics  of 
"sore  throat"  in  England,  we  have  few  reliable  accounts, 
and  even  of  the  origin  and  progress  of  the  late  epi- 
demics of  diphtheria,  our  knowledge  is  far  from  being 
either  accurate  or  satisfactory.  We  have  already  alluded 
to  the  description  of  the  epidemics  of  throat  disease 
by  Fothergill  and  Huxham,  about  the  middle  of  the  last 
century,  as  also  to  the  admirable  paper  of  Dr.  Starr. 
The  first  of  these  writers,  as  we  have  seen,  speaks  dis- 
tinctly of  sloughs  in  the  fauces  which  leave  ulcers. 
Huxham  and  Starr  speak  of  the  exudation  extending  to 
the  air-passages.  It  is  not  a  little  remarkable,  that  the 
same  neighborhood  in  Cornwall  (Liskeard  and  the  other 
towns  in  which  the  epidemic  of  ulcerous  sore  throat 
described  by  Dr.  Huxham  prevailed),  has  been  subject 
5 


60  diphthp:ria. 

during  the  last  three  years  to  a  similar  affection,  and 
which  closely  resembles  the  disease  described  by  M. 
Becquerel,  inasmuch  as  the  membranous  exudation  of 
unusual  thickness  is  associated  with  softening  and 
destruction  of  the  submucous  tissue.  This  epidemic 
has  been  well  described  by  Mr.  Thompson,  of  Laun- 
ceston.' 

"About  three  years  since,  this  neighborhood  was 
visited  by  an  epidemic  of  this  disease.  The  first  cases 
occurred  in  the  town ;  and  no  others  then  appeared  for 
several  months,  when  it  again  broke  out  in  the  district 
north  of  this  place,  where  it  prevailed  for  several 
months ;  whilst  the  south  side  was  comparativel}^  free 
from  it.  From  the  north  it  gradually  spread  until  the 
whole  line  of  country  had  been  visited  by  it.  There 
appeared  to  be  no  difference  in  the  geological  nature  of 
the  country,  the  level,  or  the  aspect,  in  increasing  the 
severity,  or  granting  an  immunity  from  the  disease. 
The  premonitory  symptoms  varied  somewhat.  A  few 
retired  to  rest  comparatively  well,  and  awoke  in  the 
morning  with  the  throat  sore,  and  covered  with  white 
deposit.  In  the  majority  it  was  preceded  by  all  the 
ordinary  symptoms  of  pyrexia,  of  which  headache  was 
one  of  the  most  severe ;  followed  in  the  course  of  a  day 
or  two  by  the  usual  throat  symptoms.  An  extreme 
feeling  of  depression,  not  to  be  accounted  for  by  the 
amount  of  mischief  in  the  throat,  was  a  characteristic 

'  Brit.  Med.  Journal,  June,  1858. 


HISTORY.  51 

symptom  in  eacTi  case.  An  external  examination  of  the 
throat  showed  the  tonsil  generally  to  be  swollen,  hard, 
and  tender  to  the  touch ;  whilst  sometimes  the  parotid 
gland  participated  in  the  swelling.  Internally  the  tonsil 
was  swollen,  and  either  covered  with  the  diphtheritic 
deposit  which  frequently  extended  over  the  pharynx, 
and  sometimes  into  the  nares  and  palate;  or  else  it 
would  be  scooped  out  into  an  ulcer  with  raised  violet- 
colored  edges;  the  floor  exhibiting  a  dark  ash-colored 
slough.  In  some  instances  there  would  be  no  deposit  or 
ulceration  at  first,  but  simply  the  tonsil  painful  and  en- 
larged. These  cases  generally  change  for  a  state  of 
ulceration,  which  began  in  several  distinct  spots,  and 
gradually  spread  over  the  whole  tonsil.  In  the  most 
severe  examples,  the  tonsil  sometimes  sloughed  en  masse. 
I  saw  one  instance  in  which  this  occurred  in  an  early 
stage  of  the  disease,  and  where  now  (two  years  since  it 
occurred)  a  cavity  remains  capable  of  containing  a 
pigeon's  egg,  across  the  surface  of  which  extends  a  small 
band  of  mucous  membrane  which  did  not  slough  at  the 
same  time,  and  gives  great  inconvenience  from  retaining 
the  food  impacted  in  the  hollow  during  deglutition.  I 
have  seen  no  case  in  which  I  could  detect  the  extension 
of  the  disease  into  the  oesophagus ;  but  in  many  it  has 
entered  into  the  air-passages,  this  being  the  most  fre- 
quent and  most  fatal  complication." 

"It   can   scarcely  fail   to  strike  the  reader   that   the 
affection  under  consideration  would  be  just  as  correctly 


52  DIPHTHERIA. 

designated  by  tlie  term  'sore  tliroat  witli  ulcers,'  em- 
ployed by  nuxbam  and  Fothergill,  as  by  that  of  diph- 
theria, a  fact  which  appears  the  more  remarkable  when 
w^e  consider  that  the  very  towns  in  which  Iluxham's  dis- 
ease most  prevailed  in  1748-50,  have  been  most  severely 
visited  during  the  last  few  years.  Are  these  two  epi- 
demics, separated  by  an  interval  of  more  than  a  century, 
of  the  same  nature?  A  careful  comparison  of  their 
symptoms  assures  us  that  they  are,  and  that  Bretonneau, 
in  disclaiming  all  relationship  between  his  diphtheria 
and  the  '  sore  throat  with  ulcers,'  was  mistaken."^ 

As  we  have  before  remarked,  in  the  year  1765  Dr. 
Home  published  a  small  treatise^  upon  a  disease  of  the 
larynx  which  had  long  been  known,  but  the  characters 
of  which  had  never  been  clearly  defined.  To  this  he 
gave  the  name  of  croup,  and  upon  this  essay  the  modern 
doctrine  of  croup  is  based.  Home's  description  is  based 
upon  the  careful  observation  of  twelve  cases,  in  ten  of 
which  post-mortem  examinations  were  made.  He  first 
pointed  out  that  the  formation  of  a  false  membrane  is 
essential  to  the  disease,  and  that  its  presence  in  the 
larynx  is  the  source  of  danger.  Others  also  published 
their  observations  upon  this  disease,  among  whom  were 
Cheyne  and  Cullen.  The  affection  described  by  these 
writers  is  essentially  different  from  the  croup  of  Breton- 
neau. 

'  Brit,  and  For.  Med.-Cliir.  Review,  Jan.  18G0. 

2  Inquiry  into  the  Nature,  Cause,  and  Cure  of  Croup,  Edinb.,  17G5. 


HISTORY.  53 

From  this  time,  until  its  recent  outbreak,  although  we 
may  gather  a  few  scattering  allusions  to  diphtheria  from 
British  medical  literature,  it  was  a  disease  practically 
unknown  to  even  the  most  experienced  of  English 
practitioners,  certainly,  in  the  form  in  which  it  has  of 
late  presented  itself. 

The  advent  of  the  present  epidemics  of  the  disease 
attracted  public  attention  in  England,  in  the  autumn  of 
1857,  a  few  cases  having  occurred  for  twelve  months 
previously.  It  first  appeared  in  the  southeastern  coun-^ 
ties,  especially  in  Kent,  in  the  town  of  Canterbury.  In 
Essex,  particularly  in  the  marshy  districts,  it  prevailed 
extensively;  thence  it  spread  through  all  the  eastern 
counties. 

"The  local  name  was  'throat  fever.'  It  appeared 
after  arriving  at  a  certain  stage  to  baffle  medical  skill, 
and  something  of  a  fungus  nature  showed  itself  in  the 
throat.  Croupal  suffocation  was  one  of  its  complica- 
tions, which  appears  to  eliminate  'putrid  sore  throat,' 
and  those,  therefore,  who  classify  this  Cornish  epidemic 
with  diphtheria  are  probably  warranted  in  so  doing.'" 

During  the  next  summer  months  the  disease  spread 
northwards  to  Lincolnshire  and  Yorkshire.  In  the 
winter  months  of  1858  the  southeastern  counties  still 
suffered.  In  parts  of  Essex  the  disease  was  almost 
universal. 

'  Ou  Diphtlieria,  hy  Ernest  Hart,  London,  1859. 
5^ 


54  DIPHTHERIA. 

"At  Teignmouth,  Mr.  Lake  observed  cases  of  that 
severest  form  of  diphtheric  inflammation,  in  which  the 
local  manifestation  of  the  disease  is  from  the  first  over- 
shadowed in  importance  by  the  constitutional  symptoms. 
The  blood-making  powers  were  seriously  compromised 
after  the  annihilation  of  the  throat  affection,  the  patient 
sinking  then  through  general  failure  of  the  powers  of 
life,  without  anything  like  typhoid  symptoms,  a  distinc- 
tion which  it  is  very  important  to  maintain,  or  being  left 
in  a  state  in  which  he  is  liable  to  be  carried  off*  by  any 
prevalent  disorder,  or  during  convalescence  continuing 
unusually  weak  and  anaemic." 

In  Suffolk,  and  in  some  of  the  eastern  counties, 
as  also  in  Nottinghamshire,  scarlatina  prevailed  in  con- 
junction with  diphtheria.  In  the  northwestern  counties 
we  find  hooping-cough  and  diphtheria  prevailing. 

In  fact  the  disease  spread  to  almost  all  parts  of  Eng- 
land, appearing  with  much  greater  severity  in  some 
localities  than  in  others.  Dr.  Hart  has  given  in  his 
report  a  very  succinct  account  of  its  progress  through 
the  country. 

If  now  we  examine  some  of  the  various  accounts  of 
the  recent  epidemics  in  England,  as  they  have  appeared 
in  different  parts  of  the  country,  there  will  be  seen  to  be 
a  considerable  amount  of  discrepance,  and,  moreover, 
many  of  the  accounts  will  be  found  to  differ  widely 
from  Bretonneau's  model.  We  select  a  few  as  they  have 
appeared  in  the  various  journals  of  the  day : — 


HISTORY.  55 

At  a  meeting  of  the  Harveian  Society,^  Dr.  B,  Sander- 
son said : — 

"That  the  disease  recently  prevalent  in  England  was 
identical  with  the  malignant  sore  throat  described  by 
many  authors,  and  that  in  a  great  number  of  instances 
scarlatina  precedes  it.  It  was  attended  with  much  fever 
and  fetid  breath,  the  fever  sometimes  of  a  typhoid  char- 
acter. The  thickness  and  adhesiveness  of  the  exudation 
were  less  marked  than  that  occurrino^  at  Tours.  In  Encr- 
land  exhaustion  and  fever  destroyed  the  patient  rather 
than  asphyxia,  which  suddenly  put  an  end  to  Breton- 
neau's  patients.  In  true  diphtheria  there  was  no  fever 
and  no  fetid  breath ;  both  these  were  remarked  in  this 
country.  Finally,  he  believed  croup  and  diphtheria 
identical,  and  that  the  disease  in  England  was  not  diph- 
therite,  but  the  pultaceous  pharyngitis  of  the  French." 

Dr.  Laycock,  of  Edinburgh,  in  a  clinical  lecture, 
published  in  May,  1858,  regards  diphtheria  as  a  disease 
produced  by  a  fungous  growth — "oidium  albicans" — ■ 
similar  to  that  found  in  thrush.     He  says: — 

"If  the  fungus  multiply  in  a  population  at  the  same 
time  that  there  is  an  epidemic  of  scarlatina  or  rubeola 
prevalent,  that  epidemic  may  be  expected  to  take  the 
diphtheritic  form." 

His  remarks,  however,  appear  to  be  based  solely  on 
the  following  case,  in  which  there  was  an  aphthous 
affection  of  the  mouth  and  throat. 

James  D ,  aged  35,   married — admitted  into  the 

•  Lancet,  Oct.  ]858. 


56  DIPHTHERIA. 

Infirmary  Marcli  19 — stated  that,  until  two  years  ago, 
his  health  was  good.  About  that  time  he  had  diarrhoea 
with  frequent  desire  to  go  to  stool,  and  much  straining 
at  stool  without  result.  A  few  weeks  afterwards  had 
shiverings  and  sweatings,  and  a  peculiar  feeling  of 
numbness,  with  loss  of  sensibility  in  upper  and  lower  ex- 
tremities. The  arms  would  become  stiff.  At  present, 
the  attacks  of  stiffness  come  on  only  when  his  hands  are 
placed  behind  the  back.  Continued  at  work  until  eight 
days  ago. 

On  examination  it  was  found  that  he  slept  well, 
swallowed  easily,  had  no  pain  after  eating,  but  was  flatu- 
lent. Bowels  regular,  motions  solid.  Abdomen  large 
and  tumid.  Urine  of  spec.  grav.  100.5,  no  albumen,  no 
sugar — amount  seventy  ounces  per  diem.  Under  the 
microscope,  the  blood  was  seen  to  contain  colorless  cor- 
puscles in  slightly  increased  quantity.  Lungs  healthy, 
no  cough  or  expectoration.  His  skin  under  the  clothing 
was  pale;  the  inner  surface  of  the  lips  pallid,  the  face  unu- 
sually brown,  but  evidently  from  atmospheric  pressure. 
In  three  weeks  after  admission,  the  bowels  became  re- 
laxed, and  by  April  13  an  obstinate  diarrhoea  had  set  in, 
which  resisted  all  the  usual  remedies.  On  the  15th  he 
complained  of  sore  throat,  and  on  examination,  the  fauces 
were  seen  to  be  deeply  congested,  and  covered  with 
white  spots.  The  tongue  had  also  white  patches  upon  it. 
He  still  complained  of  the  hypersesthetic  sensations  in 
his  arms,  and  was  hopeless  as  to  his  recovery.  On 
April  23,  pulse  120,  deglutition  difficult,  with  a  constant 


HISTORY.  57 

burniDg  pain  in  the  throat.  On  the  24th  the  pharynx 
was  seen  to  be  covered  with  a  thick  yellowish  pellicle, 
and  the  surface  beneath,  when  it  was  detached,  was  raw 
and  bleeding.  The  pellicle,  when  a  fragment  was  placed 
under  the  microscope,  was  found  to  consist  of  the 
mycelium  and  sporules  of  the  oidium  albicans,  with  epi- 
thelium and  pus  cells.  He  was  ordered  'the  aqua  chlo- 
rinata,  and  a  solution  to  the  fauces  of  nitrate  of  silver. 
....  The  patient  gradually  sank  until  the  morning  of 
the  11th  inst.,  when  he  died.  - 
Autopsy. — On  removing  the  tongue,  trachea  and 
oesophagus,  it  was  found  that  a  soft  yellowish- white  pul- 
taceous  matter  was  adherent  to  the  mucous  membrane  of 
the  tongue,  pharynx,  and  oesophagus.  This  occurred  in 
some  places  as  a  continuous  layer,  in  other  places  as 
patches.  It  could  be  readily  scraped  ofl^  when  the 
mucous  membrane  was  found  to  present  a  somewhat  raw 
appearance.  It  was  most  abundant  in  the  pharynx  over 
the  back  of  the  larynx.  The  matter  extended  down  the 
oesophagus  to  within  two  inches  of  the  stomach.  On 
examining  microscopically  the  matter  found  on  the 
mucous  membrane,  it  was  seen  to  consist  of  the 
branching  filaments  and  sporules  of  the  oidium  albicans, 
mixed  with  large  quantities  of  somewhat  altered  epi- 
thelial scales.  The  larynx  and  trachea  were  quite  natu- 
ral  The   mesentery  was   found   to  be  converted 

into  a  large  cancerous  mass;  the  lumbar  glands  and 
supra-renal  capsules  were  also  implicated  in  the  same 
disease. 


58  DIPHTHERIA. 

Comment  hy  Dr.  Lmjcoch. — The  immediate  cause  of 
death  was  the  exhausting  diarrhoea.  Now  this  super- 
vened coincidently  with  an  attack  of  diphtheria.  At 
the  onset  of  the  disease,  and  just  at  the  period  before 
death,  we  found  in  the  pellicle  formed  on  the  tongue 
and  fauces,  the  sporules  and  mycelium  of  the  o'idium 
albicans,  a  parasitic  fungus  found  also  in  muguet,  the 
epidemic  aphtha  or  diphtheria  of  infants  in  France. 
This  is  an  interesting  fact  at  the  present  moment,  when 
diphtherite  is  prevailing,  more  especially  as  the  pellicle 
was  also  found  abundantly  after  death  in  the  oesophagus. 
I  have  little  doubt  that  this  pellicle  was  due  to  the  action 
of  the  parasite  on  the  enfeebled  mucous  surface  of  the 
mouth,  fauces,  &;c.  It  acts  like  all  its  tribe,  as  an  irritant 
inducing  increased  formation  of  epithelial  scales,  and 
effusion  of  mucous  exudation,  corpuscles  or  plasma; 
intermingled  among  these  are  the  sporules,  and  the 
mycelium  of  the  microscopic  fungus ;  the  whole  consti- 
tutes a  pellicle  or  membrane,  varying  in  thickness. 
(Fig.  1.)  The  parasite  seems  to  act  upon  the  capillaries 
of  the  subjacent  tissue,  as,  when  removed,  blood  is  not 
uncommonly  effused,  and  the  surface  looks  raw.  Diph- 
theria is  not,  however,  limited  to  one  form  of  disease. 

....  If  the  fungus  multiply  in  a  population  at  the 
same  time  that  there  is  an  epidemic  of  scarlatina  or 
rubeola  prevalent  therein,  that  epidemic  may  be  ex- 
pected to  take  the  diphtheritic  form  in  those  cases  which 
are  attacked  by  the  o'idium.  I  must  add,  however,  that 
we    have   had   reasons   for   thinking    that   the  oidium, 


HISTORY, 


59 


acting  alone,  will  fasten  upon  tlie  mucous  membrane  of 
the  mouth  and  throat,  and  excite  inflammation  and 
without  the  formation  of  a  pellicle The  diagnosis 


Fig.  1. 


The  sporules  and  the  mycelium  of  the  o'idium.     After  Eobia, 

of  diphtheritic  oidium  from  ordinary  aphtha  is  founded, 
first,  on  the  character  of  the  morbid  appearance,  for,  in 
ordinary  aphtha,  the  disease  is  vesicular,  and  the  white 
specks  or  patches  are  ulcers,  while  in  diphtheria,  they 


60  DIPHTHERIA. 

are  pellicular,  and  not  ulcerative,  while  the  redness  is 
much  deeper  than  in  aphtha.  Besides,  the  microscope 
may  reveal  the  spores  and  mycelium  of  the  fungus.  The 
development  of  the  mycelium  is,  however,  by  no  means 
a  necessary  result  of  the  action  of  the  fungus.  This 
seems  to  be  peculiar  to  the  more  advanced  stages;  at 
first  there  is  not  even  a  pellicle,  only  characteristic  red- 
ness of  the  affected  surface Further,  it  is  pro- 
bable that  besides  the  stage  of  development,  the  condition 
of  the  hahiiat  may  make  a  considerable  difference  as  to 

the  mordid  products How  great  a   share  these 

microscopic  parasitic  organisms  have  in  the  causation  of 
disease,  remains  yet  to  be  ascertained. 

In  answer  to  remarks  made  by  Dr.  Kogers,  that  he  not 
only  thinks  diphtheria  to  be  a  blood  disease,  but  that,  as 
such,  it  cannot  be  a  parasitic  disease.  Dr.  Laycock  says 
{Lancet,  Jan.  22  and  29,  1859):  "Comparative  pathology 
teaches,  however,  that  this  conclusion  is  at  least  doubt- 
ful. The  muscardine  (an  epizootic  disease  of  the  silk- 
worm) is  due  to  a  species  of  fungus  like  that  which 
infects  the  potato,  called,  after  its  discoverer,  the  Botrytis 
bassiana,  and  the  sporules  are  described  as  being  repro- 
duced in  the  blood  of  the  insect  when  it  becomes  acid ; 
while  the  filaments  and  mycelium  appear  on  the  respi- 
ratory surfaces,  that  is,  at  the  outlets  of  the  tracheal 
tubes. 

"  Again,  the  fungus  of  the  common  house  fly  (Mj^co- 
phyton  Cohnii)  is  a  mould  or  oidium  found  in  the  blood, 
abdomen,  and  sometimes  in  the  intestines  of  the  insect  at 


HISTORY.  61 

beginning  of  autumn.  Its  first  symptom  o"bservecl,  is  a 
milky  appearance  of  the  blood.  It  is  found  in  tlie  blood 
in  all  stages  of  development,  from  tlie  simple  minute 
spore  or  cell,  to  the  full-grown  mycelium.  It  is  found 
in  like  manner  in  the  fluids  of  the  intestines,  and  appears 
externally  as  a  mould.  Flies  thus  affected  may  be  often 
seen  sticking  with  outstretched  wings  to  the  window 
panes  at  the  end  of  the  summer  and  beginning  of  autumn. 
These  are  by  no  means  solitary  instances  of  parasitic 
blood  disease.  Indeed,  hamatophyta,  as  Lebert  terms 
these  microscopic  blood  parasites,  infest  the  blood  of 
several  classes  of  insects.     The  same  facts  also  hold  good 

as  to  the  vegetable  parasites These  are  facts 

which  ought  to  make  us  hesitate,  at  least  in  coming  to 
the  conclusion,  in  the  absence  of  all  inquiry,  that  a 
parasitic  disease  cannot  be  a  blood  disease  in  man. 

....  "That  these  parasites  are  sometimes  powerful 
irritants  of  the  lining  tissues,  is,  I  think,  fully  established 
both  from  the  history  of  muguet  and  other  circum- 
stances, and  although  French  writers  speak  of  X'^eudo- 
diphtherite,  the  accuracy  of  the  term  may  be  ques- 
tioned, for  the  exudation  appears  externally  on  ulce- 
rated or  exposed  surfaces,  as  well  as  internally,  in  both 
muguet  and  diphtheria  alike.  An  interesting  case  of 
vaginal  blennorrhoea,  due  probably  to  oidium  albicans 
introduced  from  without,  may  be  found  in  ArcMv  fur 
Fhysiologle,  vol.  ix.  p.  466.  The  labia  were  swollen,  the 
vagina  of  a  bright-red,  studded  with  enlarged  papillae, 
and  covered  with  star-like  patches  of  membrane,  like 
6 


62  DIPHTHERIA. 

those  of  the  mouth  in  muguet^  which  were  found  to 
contain  the  0.  albicans.  The  patient  in  the  next  bed 
had  subsequently  active  fever,  abdominal  tenderness,  O. 
albicans  of  the  mouth  with  muguet. 

''  It  is  usual  to  speak  of  the  characteristic  pellicle  as 
if  it  were  peculiar  to  diphtheria,  but  this  is  by  no  means 
the  case.  It  is  not  unfrequently  seen  in  cases  of  typhus 
and  relapsing  fever,  sometimes  in  yellow  fever,  and  I 
believe  in  all  fevers.  A  series  of  carefully  conducted 
experiments,  made  with  a  thorough  knowledge  of 
crj^ptogamic  botany  on  lower  animals  so  as  to  show  the 
real  pathological  origin  and  the  effects  of  these  parasitic 

fungi,  would  be  very  valuable I  am  inclined 

to  think  that  it  would  probably  be  shown  that  these 
parasites  may  act  either  through  the  blood  or  locally 
only. 

"I  may  observe,  in  conclusion,  that  antiseptics  and 
parasiticides  appear  to  be  the  most  efficient  remedies  in 
diphtheria.  I  can  speak  very  favorably  of  the  tinct.  of 
the  sesquichloride  of  iron  (an  antiseptic  and  hydro- 
chlorate  of  potass)." 

Dr.  Kingsford,'  in  a  letter  to  the  Lancet,  thus  speaks 
of  the  disease  as  it  has  come  under  his  observation : — 

"Diphtheria  may  be  divided  into  the  mild  and  severe 
forms. 

''The  mild  form,  which,  for  the  sake  of  distinction, 
may  be  designated  the  diphtheritic  sore  throat,  is  ushered 

Lancet,  Nov.  1858. 


HISTORY.  63 

in  by  a  variable  amount  of  feverishness,  loss  of  appetite, 
and  at  first  only  slight  pain  in  swallowing ;  the  tongue 
presents  a  thick,  white,  creamy  coat,  through  which 
some  of  the  papillas  are  visible ;  the  velum  palati,  uvula, 
and  pharynx  are  of  a  bright  red  color ;  the  tonsils  are 
much  swollen,  and  of  the  same  livid  hue,  and  upon  the 
inner  side  of  one  or  both  of  them  distinct  white  patches 
are  seen,  which  in  some  instances  resemble  an  exudation 
from  the  sulci  of  the  tumid  gland,  but  more  frequently 
are  flat  and  filmy  in  appearance,  not  confined  to  the 
tonsils  alone,  but  spread  over  the  uvula  and  posterior 
wall  of  the  pharynx ;  both  the  exudation  and  the  filmy 
deposit  adhere  tenaciously  to  the  submucous  surface, 
and  cannot  easily  be  scraped  off.  Ulcerative  stomatitis 
not  rarely  precedes  and  accompanies  this  mild  form  of 
diphtheria — indeed,  by  some  they  are  considered  to  be 
identical ;  the  parotid  and  submaxillary  glands-  are  not 
much  swollen,  although  one  or  two  enlarged  glandulas 
concatenat^e  may  often  be  detected. 

"The  severe  form,  or  genuine  diphtheria,  is  always 
characterized  by  a  high  state  of  fever,  hot,  pungent  skin, 
flushed  countenance,  congested  lips,  a  rapid,  feeble  pulse, 
great  difficulty  in  swallowing,  and  hurried  respiration ; 
the  tongue  is  covered  by  a  thick,  dirty,  yellowish-brown 
or  sometimes  slaty-colored  coat ;  the  velum  palati,  uvula 
and  pharynx  are  of  a  deep,  dark,  erysipelatous  redness ; 
the  tonsils  usually  enormously  swollen,  and  of  the  same 
dark  red  color,  but  instead  of  the  white  patches  ob- 
served in  the  mild  form  a  large  ash-colored  membrane 


64:  DIPnTITERIA. 

is  spread  over  the  inner  side  of  one  or  both  tonsils,  and 
also  upon  the  uvula  and  posterior  wall  of  the  pharynx. 
As  the  disease  advances,  the  above  symptoms  increase 
in  severity;  the  breathing  becomes  stertorous  from 
mechanical  obstruction;  deglutition  so  painful  that 
young  children  will  refuse  to  swallow  even  liquids ;  the 
saliva  dribbles  from  the  mouth,  and  a  foul  acrid  dis- 
charge often  flows  from  the  nares;  the  pulse  becomes 
more  rapid  and  feeble ;  the  glands  of  the  neck  are 
now  swollen  and  tender,  and  the  voice  is  hoarse  and 
indistinct;  the  patient  restless,  tosses  about  upon  the 
bed,  or  else  lies  on  his .  back  in  a  semi-comatose  state. 
These  cases,  Avhen  fatal,  terminate  either  by  rapid  pros- 
tration of  the  vital  powders,  or  by  an  affection  simulating 
croup,  from  extension  of  the  diphtheritic  membrane  into 
the  air-passages ;  in  both  instances  death  is  usually  pre- 
ceded by  obstinate  vomiting,  probably  the  result  of 
inflammation  or  irritation  of  the  par  vagum.  .  .  . 

"  In  fatal  cases,  the  2^ost-mortem  examination  reveals 
the  ash-colored  membrane  spread  over  the  pharynx, 
extending  to  the  posterior  nares  and  down  the  oeso- 
phagus; but  when  death  is  preceded  by  symptoms  of 
cronp,  it  is  found  also  in  the  larynx  and  trachea.  Upon 
detach  in  q:  this  membranous  exudation,  the  submucous 
surface  presents  an  ecchymosed  appearance,  but  no  dis- 
tinct signs  of  ulceration." 

Dr.  Ileslop,  in  a  communication  to  the  Medical  Times 
(Did  Ga?:ctie,^  expresses  his  belief  that,  although  so  little 

'  May  29,  1858. 


HISTORY.  65 

known  now,  this  disease  was  well  understood  and  de- 
scribed by  former  British  authors,  especially  Fothergill. 
It  is  a  pestilence  with  well-marked  features.  It  is  con- 
tagious, though  not  highly  so,  and  its  ataxic  phenomena 
are  most  striking — prostration,  quite  disproportionate  to 
the  amount  of  disease  in  the  throat,  coming  on  early, 
and  remaining  after  all  other  indications  of  disease  have 
passed  away.  In  the  worst  cases  a  foul,  ulcerous  condi- 
tion of  the  fauces  complicates  the  genuine  membranous 
angina.  The  mode  of  death,  as  in  other  pestilences,  is 
by  asthenia,  and  frequently  the  event  is  sudden  and  un- 
looked  for. 

Dr.  Heslop  points  out  in  detail  the  differences  between 
this  affection  and  croup. 

Dr.  Whitehead,  in  the  same  journal,  describing  the 
disease,  states  that  the  symptoms  are  very  similar  to 
those  of  croup,  but  that  they  come  on  suddenly,  without 
the  peculiar  crowing,  after  what  seems  a  slight  sore 
throat.  On  examining  the  fauces  then,  they  are  found 
red  and  dry,  the  tonsils  dripping  with  a  thick,  opaque, 
offensive  matter.  Sometimes  there  is  also  great  external 
swelling  of  the  throat. 

Dr.  Camps'  believes  that  three  distinct  varieties  of  the 
disease,  if  not  three  distinct  diseases,  have  prevailed. 
1.  Cases  which  have  presented  a  precise  resemblance  to 
those  described  by  Bretonneau.  2.  Other  cases  present- 
ing many  of  the  characters  of  the  Fothergill  sore  throat. 

'  Med.  Times  and  Gazette,  Marcli,  1853. 
6^ 


66  DIPHTHERIA. 

3.  Cases  consisting  in  the  sore  throat  accompanj-ing 
scarlatina,  whether  the  eruption  has  been  present  or  not. 
The  type  of  diphtheria,  properly  so  called,  is  essentially 
asthenic. 

Dr  Pollock^  conceives  that  Bretonneau  had  painted 
the  disease  too  strongly.  True  diphtheria,  so  described; 
was  not  a  prevalent  disease,  but  many  cases  more  or  less 
approached  it.  All  such  arose  from  poisonous  influ- 
ences, and  however  different,  were  yet  identical.  In  the 
same  family  these  throat  affections  may  approximate  to 
and  diverge  from  the  diphtheritic  type,  there  being  in 
some  exudations,  in  others  ulceration  and  excoriation. 
Mr.  Bottomley,^  of  Croydon,  remarks  as  follows : — 
''  It  appears  to  me  that  at  the  commencement  of  the 
attack  there  is  but  a  slight  congestion  of  the  mucous 
membrane  of  the  pharynx,  accompanied  with  slight 
constitutional  disturbance ;  but  in  a  few  hours  the 
membrane  puts  on  a  livid  appearance,  and  runs  rapidly 
into  the  gangrenous  state ;  and  that  the  false  membrane 
is  a  deposit  of  layers  of  lymph  in  the  early  stage  of  the 
disease,  which  soon  loses  its  vitality,  and  acts  as  an 
extraneous  body,  thereby  preventing  the  parts  from 
performing  their  natural  functions,  and,  accompanying 
this  change,  great  depression  of  the  vital  powers  of  the 
system  takes  place." 

Mr.  Thomas  Smith,  of  Kent  County,  writes : — 

"  There  are  three  forms  in  which  the  disease  presents 

>  British  Medical  Journal,  July,  1859.  ^  Hjja. 


HISTORY.  67 

itself,  viz  :  simple  ash-colored  diphtheritic  membrane  in 
patches,  with  very  slight  congestion  of  the  surrounding 
parts,  and  without  fetor;  secondly,  a  deeper  color,  and 
more  widely  spread  membranous  exudation,  with  fetid 
breath,  and  intense  engorgement  of  dark  hue ;  thirdly, 
the  membrane  with  much  tonsillitis,  in  a  few  cases 
resulting  in  quinsy.  But  there  has  been  a  fourth  and 
more  formidable  state  of  things  to  contend  with,  viz., 
an  extension  of  the  membrane,  in  either  of  the  above 
forms,  to  the  lar3'nx  and  trachea.  .  .  .  Lately  there  has 
been  more  tonsillitis,  and  frequently  superficial  ulcera- 
tion.    There  is  a  depression  of  the  vital  powers. 

"In  observing  the  progress  of  this  epidemic,  I  have 
been  instinctively  led  to  reflect  on  the  altered  type  of 
disease  in  general.  I  have  myself  no  doubt  of  that 
alteration  in  the  type  of  disease  observed  since  the  year 
1832  in  England." 

Mr.  Cammach,^  of  Bennington,  remarks  : — 
"  Diphtheria  was  epidemic  in  this  district  last  year,  in 
November  and  December,  and  has  been  so  again  since 
July.  Diphtheria  varies  in  extent  from  simple  herpes 
of  the  lips  or  nose,  which  are  covered  with  vesicles 
which  burst,  ulcerate,  and  heal  in  two  or  three  days, 
to  the  most  extensive  inflammation  and  sloughing  and 
ulceration  of  the  cheek,  the  palate,  and  the  pharynx ;  and 
more  in  children  than  in  adults.  It  extends  into  the 
larynx  and   trachea,  and   kills   by  asphyxia.      In   the 

'  Lancet,  Oct.  1858. 


68  DIPHTHERIA. 

mildest  form  there  is  a  tendency  to  ulceration  beneath  a 
white,  loosely  attached  membrane.  ...  In  the  worst 
cases  its  vesicular  nature  can  be  distinctly  traced,  for  a 
few  hours  after  its  commencement,  from  the  large  patch 
within  the  cheek  or  upon  the  gum,  which  will  slough 
like  cancrum  oris,  to  the  more  diffused  bullae  upon  the 
soft  palate  and  pharynx." 

Dr.  Moncton,  in  a  letter  to  the  Medical  Times  and 
Gazette,  June,  1857,  says  : — 

"Diphtheria  is  a  distinct  disease,  easily  recognized,  and 
not  to  be  dreaded  till  such  changes  have  occurred  about 
the  fauces  and  tonsils  as  it  is  impossible  to  overlook. 
A  remote  kinship  there  certainly  is  between  it  and  scar- 
let fever,  but  identical  they  are  not.  .  .  .  Though,  as  the 
diphtheritic  membrane  loosens  and  separates  from  the 
surface  of  the  throat  and  tonsil,  sloughing  ulceration 
may  ensue,  I  feel  at  present  fully  persuaded  that  diph- 
theria and  cynanche  maligna  are  not  the  same  thing.  .  . 
The  constitutional  symptoms,  at  first  altogether  slight, 
become  very  real  as  the  disease  advances.  The  main 
feature  is  prostration,  not  typhoid  at  all — no  coma,  no 
sensorial  disturbance  throughout,  no  sordes,  no  heavy 
lurid  look;  and  in  many  cases  the  practitioner,  if  not 
warned  by  previous  experience,  or  a  careful  observation 
of  the  pulse,  is  surprised  to  learn  that  the  patient  he  left 
with  clear  countenance,  cheerful  manner,  and  little 
suffering,  a  few  hours  ago,  has  just  gone  off,  while  casu- 
ally sitting  upright,  in  a  fatal  syncope.  .  .  .  The  practi- 
cal fact  is,  however,  this,  that  after  the  fourth  or  fifth  day 


HISTORY.  69 

a  diphtheritic  patient  becomes  the  subject  of  very  real 
asthenia,  not  so  much  perceived  by  the  patient  as  dis- 
covered by  the  lax  pupil  and  feeble  pulse,  and  that  this 
state  is  the  one  which,  about  the  eighth  day,  is  too  apt  to 
terminate  in  death." 

Dr.  Copeman,  in  an  essay  on  diphtheria,  recently  pub- 
lished, remarks : — 

"  On  turning  our  attention  to  the  features  presented 
by  the  present  epidemic,  we  shall  find  that,  as  a  general 
rule,  the  constitutional  symptoms  bear  but  little  propor- 
tion to  the  local  mischief,  and  the  danger  chiefly  to  be 
feared  is  the  extension  of  the  folse  membrane  into  the 
larynx  and  trachea,  so  as  to  produce  suffocation  in  the 
same  way  as  in  croup.  .  .  . 

"  It  is  true  that  on  the  first  appearance  of  the  epidemic, 
in  several  instances  it  knocked  down  its  victims  at  once, 
showing  itself  as  a  poison  too  powerful  to  give  time  for 
the  development  of  any  decided  symptoms,  either  con- 
stitutional or  local.  But  this  is  a  character  common  to 
almost  all  severe  visitations  of  epidemic  disease  at  their 
first  onset,  and,  as  I  have  said  before,  many  of  the 
patients  who  have  since  died  from  it  have  exhibited  no 
very  marked  constitutional  disturbance." 

Thus  it  will  be  seen  from  these  various  accounts  of 
the  disease,  as  it  manifested  itself  in  Great  Britian,  that 
not  only  was  a  distinct  loss  of  substance  in  the  fauces 
frequently  observed,  but  that  the  great  prostration  and 
general  constitutional  disturbance  did  not  fail  to  attract 
the  attention  of  almost  every  practitioner. 


70  DirnTHEEIA. 

If  the  materials  for  a  full  and  satisfactory  account  of 
tlie  epidemics  of  sore  throat  wliicli  have  prevailed  in 
Great  Britian  are  scanty,  tlicy  are  very  much  more  so  as 
regards  our  own  country. 

Dr.  Douglas,  of  Boston,  in  the  year  1736,  published 
an  account  of  the  first  appearance  of  a  "sore  throat  dis- 
temper" in  this  country.  This  account  is  alluded  to  by 
Dr.  Bard  in  his  valuable  paper.^  The  epidemic  which 
he  describes  was  very  malignant,  and  was  attended 
with  erysipelatous  appearances  and  highly  putrid  symp- 
toms. 

In  the  first  volume  of  Medical  Ohservalions  and 
Inquiries,  published  in  London  in  1771,  is  an  extract 
from  a  letter  from  Mr.  Cadwallader  Golden  to  Dr. 
Fothergill,  concerning  the  throat  distemper,  dated — 
Goldenham,  New  York,  October  1,  1753.     lie  says : — 

"  The  first  appearance  of  the  throat  distemper  was  at 
Kingston,  an  inland  town  of  New  England,  about  1735. 
It  spread  from  thence,  and  spread  gradually  westward, 
so  that  it  did  not  reach  Hudson's  Kiver  till  nearly  two 
years  afterwards.  It  continued  on  the  east  side  of 
Hudson's  Eiver  before  it  passed  to  the  westward,  and 
appeared  first  in  those  places  to  which  the  people  of  New 
England  resorted  for  trade,  and  in  the  places  through 
which  they  travelled.  It  continued  to  move  westwardly, 
till,  I  believe,  it  has  at  last  spread  over  all  the  British 

'  Researches  on  the  Nature,  Causes,  and  Treatment  of  SufTocativo 
Angina,  kc.     By  Samuel  Bard,  M.  D.,  New  York. 


HISTORY.  71 

Colonies  on  the  Continent.  Children  and  young  people 
were  only  subject  to  it,  with  a  few  exceptions  of  some 
above  twenty  or  thirty,  and  a  very  few  old  people  who 
died  of  it.  The  poorer  sort  of  people  were  more  liable 
to  have  the  disease  than  those  who  lived  well  with  all 
the  conveniences  of  life,  and  it  has  been  more  fatal  in  the 
country  than  in  great  towns. 

''In  some  families  it  passed  like  a  plague  through  all 
their  children;  in  others,  only  one  or  two  were  seized 
with  it.  Ever  since  it  came  into  the  part  of  the  country 
where  I  live  (now  about  fourteen  years),  it  frequently 
breaks  out  in  different  families  and  places  without  any 
previous  observable  cause,  but  does  not  spread  as  it  did 
at  first.  It  seems  as  if  some  seeds,  or  leaven,  or  secret 
cause  remains  wherever  it  goes.  When  the  distemper 
becomes  obvious,  it  has  the  common  symptoms  attending 
a  fever,  except  that  a  nausea  or  vomiting  is  seldom  ob- 
served to  accompany  it. 

"It  is  attended  with  a  moist  putrid  heat,  the  skin 
being  seldom  parched.  The  pulse  is  usually  low,  but 
frequent  and  irregular.  The  countenance  dejected,  with 
lowness  of  spirits;  no  considerable  thirst;  the  tongue 
much  furred,  and  the  furring  sometimes  extends  all  over 
the  tonsils  as  far  as  the  eye  can  reach.  At  other  times, 
in  the  milder  kind,  the  tonsils  appear  only  swelled  with 
Avhite  specks  of  about  a  quarter  of  an  inch  or  half  an 
inch  in  diameter,  which  are  thrown  off  from  time  to  time 
in  tough,  cream-colored  sloughs.  Sometimes  all  the 
parts  near  the  gullet  or  throat  are  much  swelled  both 


72  DIPHTHERIA. 

inwardly  and  outwardty,  so  as  to  endanger  suffocation, 
and  frequently  mortify  ;  but  most  generally  ttie  swelling 
internally  is  not  so  much  as  to  make  swallowing  diffi- 
cult. Sometimes  these  swellings  impostliumate.  The 
last  complaint  is  commonly  of  an  oppression  or  strictness 
in  the  upper  part  of  the  chest,  with  difficulty  of 
breathing,  and  a  deep,  hollow,  hoarse  cough,  ending  in  a 
livid,  strangled-like  countenance,  which  is  soon  followed 
by  death.  This  disease  is  not  often  attended  with  that 
loss  of  strength  that  is  usual  in  other  fevers ;  so  that 
many  have  not  been  confined  to  their  beds,  but  have 
walked  about  the  room  till  within  an  hour  or  two  of 
their  death ;  and  it  has  often  appeared  no  way  dangerous 
to  the  attendants,  till  the  sick  were  in  their  last  agony. 
Some  died  on  the  fourth  or  fifth  day ;  others  on  the 
fourteenth  or  fifteenth  day,  or  even  later.  When  this 
disease  first  appeared,  it  was  treated  with  the  usual 
evacuations  in  a  common  angina,  and  few  escaped.  In 
many  families,  who  had  a  great  many  children,  all  died ; 
no  plague  was  more  destructive." 

As  we  have  before  remarked,  Dr.  Samuel  Bard,  in 
1771,  gave  a  very  faithful  description  of  an  epidemic  of 
sore  throat,  Avhich  prevailed  in  ISlew  York.  It  will  be 
seen  in  the  extracts  which  we  give  from  his  treatise, 
that  his  opinions  correspond  with  those  of  Bretonneau. 
He  recognizes  the  analogy  between  this  disease  and 
croup,  as  well  as  the  manner  in  Avhich  it  spreads  from 
the  throat  to  the  larynx.     He  observed  it  sometimes  as 


HISTORY.  73 

simple  angina ;  sometimes  as  angina  complicated  with 
larjaigitis,  and  occasionally  as  laryngitis  alone. 

In  general  the  disease  was  limited  to  children  under 
ten  years  of  age,  though  some  few  grown  persons, 
particularly  women,  had  symptoms  very  similar  to  it. 
Most  of  the  persons  attacked  were  observed  to  droop 
before  they  were  confined.  Usually,  the  first  symptoms 
were  a  slightly  inflamed  eye,  a  livid  countenance,  and 
slight  eruptions  upon  the  face.  At  the  same  time,  or 
very  soon  after,  those  who  could  speak  complained  of  an 
uneasy  sensation  in  the  throat,  but  without  much  sore- 
ness or  pain.  Upon  examination,  the  tonsils  appeared 
swelled  and  highly  inflamed,  with  a  few  white  specks 
upon  them,  which,  in  sonie  cases,  increased  so  as  to 
cover  them  all  over  with  one  general  slough ;  this,  how- 
ever, although  a  frequent  symptom,  did  not  invariably 
attend  the  disease.  The  breath  was  not  offensive,  and 
deglutition  but  very  little  impeded. 

These  symptoms  continued  in  some  cases  for  five  or 
six  days  without  creating  any  alarm  ;  in  others,  a  difli- 
culty  of  breathing  came  on  within  tv/enty-four  hours, 
especially  during  sleep,  and  was  often  suddenly  increased 
to  such  an  extent  as  to  threaten  immediate  suflbcation. 
Generally,  it  came  on  later,  increased  more  graduall}^, 
and  was  not  constant. 

This  stage  of  the  disease  Avas  attended  with  a  very 

great    and    sudden    prostration    of    strength,   a     very 

peculiar,  hollow,  dry  cough,  and   a  remarkable  change 

in  the  tone  of  the  voice.     In  some  the  voice  was  almost 

7 


71  DIPHTHERIA. 

entirely  lost,  and  would  continue  very  weak  and  low  for 
several  weeks  after  recovery.  These  symptoms  con- 
tinued for  one,  two,  or  three  days,  and  greatlj^  increased 
in  those  who  died;  purging  in  several  cases  came  on, 
the  difficulty  of  breathing  became  more  marked,  and  the 
patient  died  apparently  of  suffocation.  This  commonly 
happened  before  the  end  of  the  fourth  or  fifth  day.  One 
child,  however,  lived  under  these  circumstances  to  the 
eighth  day.  Shortly  before  he  died,  his  breath  and 
expectoration  were  somewhat  offensive ;  "  but  this  was 
the  only  instance  in  which  I  could  discover  anything 
like  a  disagreeable  smell,  either  from  the  breath  or 
expectoration." 

In  some  cases,  instead  of  the  difficulty  in  respiration, 
very  troublesome  ulcers  appeared  behind  the  ears. 

'*  These  began  with  a  few  red  pimples,  which  soon  ran 
together,  itched  violently,  and  discharged  a  great  deal  of 
very  sharp  ichor,  so  as  to  erode  the  neighboring  parts, 
and  in  a  few  days  spread  all  over  the  back  part  of  the 
ear,  and  down  upon  the  neck." 

In  a  few  cases,  swelling  of  the  parotid  and  sublingual 
glands  was  noticed.     Dr.  Bard  says : — 

"I  met  with  but  two  instances  of  an3^thing  like  this 
complaint  in  adult  persons.  Both  of  these  were  women, 
and  one  of  them  had  assisted  in  laying  out  two  of  the 
children  that  died  of  it.  At  first  her  symptoms 
resembled  rather  an  inflammatory  angina;  but,  about 
the  third  day,  the  tonsils  appeared  covered  in  some 
places  with  sloughs  resembling  those  on  the  tonsils;  her 


HISTORY.  75 

pulse  was  low  and  feeble ;  she  had  a  moist  skin,  a  dejec- 
tion of  spirits,  and  some  degree  of  anxiety,  though 
nothing  like  the  difficult  breathing  of  the  children. 

"  The  other  was  a  soldier's  wife,  who,  for  some  time 
before  she  perceived  any  complaint  in  her  throat, 
labored  under  a  low  fever.  Her  tonsils  were  swelled 
and  inflamed,  and  covered  with  sloughs  resembling 
those  of  the  children ;  but  her  breath  was  more  offen- 
sive, and  she  had  no  suffocation. 

"  I  have  had  an  opportunity  of  examining  the  nature 
and  seat  of  this  disease  from  dissection,  in  three  in- 
stances. One  was  a  child  of  three  years  okl.  Her  first 
complaint  was  an  uneasiness  in  her  throat.  Upon 
examining  it,  the  tonsils  appeared  swelled  and  in- 
flamed, with  large  white  sloughs  upon  them,  the  edges 
of  which  were  remarkably  more  red  than  the  other 
parts  of  the  throat.  She  had  no  great  soreness  in  her 
throat,  and  could  swallow  with  little  or  no  difficulty. 
She  complained  of  a  pain  under  left  breast ;  her  pulse 
was  quick,  soft,  and  fluttering.  The  heat  of  the  body 
was  not  very  great,  and  her  skin  was  moist;  her  face 
was  swelled ;  she  had  a  considerable  prostration  of 
strength,  with  a  very  great  difficulty  of  breathing;  a 
very  remarkable  hollow  cough,  and  a  peculiar  change 
in  the  tone  of  her  voice.  She  was  exceedingly  restless ; 
was  sensible,  and  when  asked  a  question,  would  give  a 
pertinent  answer;  but,  otherways,  she  appeared  dull 
and  comatose.     All  these  symptoms  continued,  or  rather 


76  DIPHTHERIA. 

increased,  until  tlie  third  night,  on  which  she  had  five 
or  six  loose  stools,  and  died  early  in  the  morning. 

"Upon  examining  the  body — which  was  done  on  the 
afternoon  of  the  day  she  died — I  found  the  fauces,  uvula, 
tonsils,  and  root  of  the  tongue  interspersed  with  sloughs, 
which  still  retained  their  whitish  color.  Upon  remov- 
ing them,  the  parts  underneath  appeared  rather  pale 
than  inflamed.  I  perceived  no  putrid  smell  from  them, 
nor  was  the  corpse  in  the  least  offensive.  The  oeso- 
phagus appeared  as  in  a  sound  state.  The  epiglottis 
was  a  little  inflamed  on  its  external  surface ;  and  on  the 
inner  side,  together  with  the  inside  of  the  whole  larynx, 
was  covered  with  the  same  tough  white  sloughs  as  the 
glands  of  the  fauces.  The  whole  trachea,  from  the 
larynx  down  to  its  division  in  the  lungs,  was  lined  with 
an  inspissated  mucus,  in  form  of  a  membrane,  remark- 
ably tough  and  firm  ;  which^  when  it  came  to  the  first 
subdivisions  of  the  trachea,  seemed  to  grow  thin  and 
disappear.  It  was  so  tough  as  to  require  no  inconsider- 
able force  to  tear  it,  and  came  out  whole  from  the 
trachea,  which  it  left  with  much  ease;  and  resembled, 
more  than  anything,  both  in  thickness  and  appearance, 
a  sheath  of  thin  chamois  leather.  The  inner  membrane 
of  the  trachea  was  slightly  inflamed ;  the  lungs,  too, 
appeared  inflamed,  as  in  peripneumouic  cases,  particu- 
larly the  right  lobe,  on  which  there  were  many  large 
livid  spots,  though  neither  rotten  nor  offensive;  and  the 
left  lobe  had  small  black  spots  on  it,  resembling  those 
marks  left  under  the  skin  by  gunpowder.     Upon  cutting 


HISTORY.  77 

into  any  of  the  larger  spots  which  appeared  on  the  right 
lobe,. a  bloody  sanies  issued  from  them  without  froth- 
ing." 

Dr.  Bard  attributes  the  prevalence  of  the  epidemic 
which  he  describes  to  a  particular  disposition  of  the  air, 
or  miasmata  sui  generis — 

"  Which  more  or  less,  according  to  particular  circum- 
stances, generate  an  acrimony  in  the  humors  and  dispose 
them  to  putrefaction;  and  which  have  a  singular  ten- 
dency to  attack  the  throat  and  trachea,  affecting  the 
mucous  glands  of  these  parts  in  such  a  way  as  to  occa- 
sion them  to  secrete  their  natural  mucus  in  greater 
quantities  than  is  sufficient  for  the  purposes  of  nature, 
and  which  in  this  particular  species,  Avhen  secreted,  is 
really  either  of  a  tougher  or  more  viscid  consistence 
than  natural,  or  is  disposed  to  become  so  from  rest  and 
stagnation." 

The  disease  he  considered  of  an  infectious  nature.  In 
the  treatment  bleeding  was  advocated,  according  to 
circumstances,  and  the  use  of  mercury,  gargles,  fomenta- 
tions, &c.,  as  local  remedies. 

AYe  have  devoted  much  space  to  the  remarks  of  Dr. 
Bard.  But  his  little  treatise  has  always  been  considered 
as  very  accurate  and  truthful  in  its  delineations,  and  as 
a  valuable  contribution  to  medical  science.  His  ob- 
servations are  quoted  by  almost  all  writers  on  this  sub- 
ject since  his  day,  and  particularly  by  Bretonneau. 

Since  the  epidemic  described  by  Dr.  Bard,  we  do  not 
find   any  other   of  a  similar   character   mentioned   by 

7* 


78  DIPHTHERIA. 

writers,  until,  iu  1831,  Dr.  Bell  speaks  of  Laving  wit- 
nessed this  af!ection  in  an  epidemic  form  in  Pliiladel^Dliia. 
For  tlie  last  few  years,  however,  as  in  England,  diph- 
theria has  been  much  more  frequently  met  with,  and  in 
some  portions  of  the  United  States,  especially  in  Cali- 
fornia, very  fatal  epidemics  have  prevailed.  The 
medical  journals  in  the  various  parts  of  the  Union  con- 
tain numerous  descriptions  of  the  disease  as  it  has  pre- 
vailed in  certain  sections.  From  a  few  of  these  we 
select  extracts. 

A  terrible  epidemic  occurred  at  San  Francisco,  and  iu 
other  towns  of  California,  in  the  autumn  of  1856.  It 
had  all  the  characters  of  pharyngeal  diphtheria.  Dr.  J. 
V.  Fougeaud^  has  published  a  monograph  on  this  epi- 
demic, in  which  he  speaks  of  the  mortality  amongst 
children  in  several  counties  around  the  Bay  of  San 
Francisco  as  having  "assumed  an  appalling  character." 

"Few  children  attacked  by  it  recovered.  The  disease 
begins  in  a  very  insidious  manner  by  a  little  engorge- 
ment or  inflammation  of  the  soft  palate,  pharynx,  and 
one  of  the  tonsils.  (The  attack  seldom  commences  on 
both  at  the  same  time,  but  soon  extends  to  both  if  not 
arrested.)  At  this  period  of  the  malady,  the  patient 
complains  but  little,  there  is  often  no  fever,  or  it  is  very 
moderate.  The  pain  in  the  throat  is  much  slighter  than 
in  the  usual  forms  of  common  sore  throat,  so  slight  in- 

•  Diphtheria:  a  Concise  Historical  aiul  Critical  Essay,  &c.     Sacra- 

nieiito,  lb58. 


HISTORY.  /y 

deed,  that  tlie  little  patients  go  about  playing  as  if 
nothing  was  the  matter.  In  some  exceptional  cases> 
however,  the  fever  and  inflammation  about  the  pharynx 
are  considerable  from  the  beginning.  The  character- 
istic signs  of  the  affection  soon  follow  this  period  of 
invasion.  They  consist  in  small  portions  (plaques)  of 
white  or  yellowish  lymph  deposited  on  the  soft  palate, 
the  tonsils,  and  the  posterior  part  of  the  pharynx.  The 
cervical  and  submaxillary  gland  becomes  inflamed  and 
swollen,  and  the  pain  in  swallowing  and  opening  the 
mouth  is  occasioned  more  by  the  engorged  state  of  the 
glands  than  by  the  internal  secretion  of  lymph.  These 
deposits  go  on  increasing  in  size  more  or  less  rapidly, 
and,  in  violent  cases,  in  a  few  hours  the  whole  cavity  of 
the  throat  is  covered  by  them.  Generally  one  side  is 
more  afi'ected  than  the  other,  and  upon  examination  the 
glands  corresponding  with  the  parts  affected  will  be 
found  more  swollen  than  those  of  the  opposite  side." 

Dr.  James  Blake,'  of  Sacramento,  in  a  memoir  on 
this  subject,  says  : — 

"The  first  effect  produced  by  the  poison  is  evidently 
on  the  nervous  system.  Drowsiness,  prostration,  or 
oppression,  are  manifested  by  infants,  or  complained  of 
by  adults,  and  when  the  disease  is  prevailing,  this  desire 
of  children  to  sleep  at  other  than  their  usual  hours 
should  awaken  our  suspicions.  The  pulse  is  accelerated 
from  the  first,  but  generally  soft  and  typhoid,  although 

'  Pacific  Med.  and  Surg.  Journal,  August,  1858. 


80  DIPHTHERIA. 

in  some  cases  it  is  for  a  few  Lours  rather  hard.  The 
temperature  of  the  skin  is  raised,  although  it  is  seldom 
harsh  or  dry,  but  frequently  moist,  or  even  covered 
with  profuse  perspiration.  There  is  seldom  any  pain, 
rarely  headache  or  backache.  The  tongue  is  usually 
coated,  edges  red,  and  papilla  prominent.  The  appetite 
may  remain  good,  and  the  digestion  unimpaired.  If  we 
examine  the  throat,  we  may,  even  within  twelve  hours 
after  the  occurrence  of  the  first  slight  symptoms,  find 
the  tonsil  covered  with  a  grayish,  pultaceous  exudation, 
which  rapidly  extends  upwards  into  the  nostrils,  and 
downwards  towards  the  larynx;  and  again  we  might 
detect  only  a  redness  of  the  tonsil,  and  a  small  point  of 
exudation  two  or  three  days  after  the  commencement  of 
the  disease,  and  at  a  time  when  the  symptoms  of  general 
prostration  had  become  alarming. 

"Again,  cases  present  themselves  in  which  the 
general  symptoms  and  the  anatomical  lesions  proceed 
Ijari  j)assu ;  but  in  almost  every  case  that  I  have  seen,  I 
have  considered  that  death  was  the  result  rather  of  the 
action  of  the  poison  on  the  system,  than  from  obstruction 
of  the  larynx.  In  from  twelve  to  twenty-four  hours 
after  the  formation  of  exudation  on  the  tonsil,  we  shall 
generally  find  the  cervical  glands  enlarged,  and  in  pro- 
tracted cases  this  enlargement  may  become  so  great  as 
to  afford  a  serious  obstacle  to  deglutition  and  respira- 
tion. I  have  seen  cases  in  which  I  think  death  was 
thus  produced,  when  the  patient  might  otherwise  have 
rallied  from  the  eftect  of  the  poison. 


HISTORY.  81 

"The  duration  of  the  disease  is  very  uncertain.  I 
have  seen  it  terminate  fatally  in  four  days  from  the  first 
ascertainable  departure  from  perfect  health,  and  this  in 
a  strong,  healthy  child,  and  I  have  witnessed  it  run 
along  for  two  or  three  weeks,  and  then  terminate  fatally. 
The  cases  that  arise  from  contagion,  and  remain  exposed 
to  the  original  source  of  contagion,  I  believe,  as  a  general 
rule,  run  a  more  rapid  course  than  the  sporadic  cases ; 
thus  we  frequently  find  two  or  three  children  in  the 
same  family  dying  within  a  day  or  two  of  each  other, 
although  the  sporadic  case  might  have  had  the  disease 
some  days  before  the  others  took  it.  This  is  probably 
owing  to  the  continued  absorption  of  the  poison  in  a 
state  of  concentration." 

In  a  communication  to  the  Bostoii  Medical  and  Surgi- 
cal Journal,  Dr.  L.  K.  Beardsley,  of  Milford,  Conn., 
writes  that — 

"This  disease  [diphtheria]  appeared  in  an  epidemic 
form  and  with  great  mortality  in  this  vicinity  during 
the  months  of  March  and  April  last.  It  first  made  its 
appearance  in  Orange,  an  adjoining  town  (which  is  in 
an  elevated  situation,  and  is  a  remarkably  healthy  place, 
with  a  sparse  population),  and  for  a  while  was  confined 
entirely  to  the  scholars  attending  a  select  school  in  the 
village.  ..." 

"Fourteen  cases  out  of  fifteen,  of  those  who  were  first 
attacked,  proved  fatal,  in  periods  varying  from  six  to 
twenty-four  days. 

"Most  persons  residing  in  the  district  where  the  dis- 


82  DIPnTHERIA.. 

ease  first  appeared  sooner  or  later  had  some  manifesta- 
tion of  the  disease.  The  period  of  incubation  varied 
from  five  to  twenty  days.  The  lymphatic  glands  were 
in  many  cases  greatly  enlarged. 

''The  first  symptom  of  this  disease — and  it  is  one 
which  we  have  never  seen  referred  to  by  any  writer  on 
the  subject — was  ijctin  in  the  ear.  It  was  not  only  patho- 
gnomoniC;  but  prominent,  and  almost  invariably  present, 
in  every  case  that  came  under  our  observation,  for  a 
day  or  two  before  the  patient  made  the  least  complaint 
in  any  other  respect,  and  before  the  smallest  point  or 
concretion  of  lymphatic  exudation  could  be  discovered 
on  the  tonsils  or  elsewhere." 

The  tonsils  were  enlarged  and  inflamed,  with  small 
points  of  lymphatic  exudation  upon  them,  which  gradu- 
ally spread  upwards  into  the  nasal  fossa3,  and  down- 
wards into  the  larynx  and  trachea.  There  was  extreme 
prostration,  depression  of  the  nervous  system,  feeble 
pulse,  &c.,  but  in  no  case  was  there  any  mental  disturb- 
ance.    There  was  nothing  peculiar  in  the  treatment. 

Dr.  Beardsley's  account  is  concise,  and  well  drawn  up. 

In  Albany,  N.  Y.,  diphtheria  assumed  an  epidemic 
character  in  1858,  proving  very  destructive.  Dr. 
Willard,  of  that  city,  in  a  paper  read  before  the  New 
York  State  Medical  Society,  states  that  it  first  appeared 
in  April,  1858,  although  its  greatest  severity  was  in 
the  autumn.  In  a  population  of  about  60,  000  there 
were  167  deaths.  Of  the  whole  number  only  three 
were  of  adults,  the  remainder  being  of  children,  mostly 


HISTORY.  83 

under  twelve  years  of  age.  The  deaths  of  females  were 
about  one-third  more  than  of  males.  One  portion  of 
the  city  suffered  more  than  another,  but  no  satisfactory 
connection  was  traced  between  the  disease  and  any  local 
cause. 

A  few  cases  of  diphtheria  have  also  been  observed  in 
Boston,  Providence,  New  Bedford,  Weymouth,  and  in 
several  other  portions  of  ISTew  England,  but  there  has 
been  no  serious  epidemic  of  the  disease  in  this  section  of 
the  country,  besides  those  we  have  mentioned. 

There  is  reason  to  believe  that  the  disease  may 
become  more  firmly  established  with  us,  as  has  been  the 
case  in  both  France  and  England. 

We  have  thus  given  some  account  of  the  epidemics 
of  "sore  throat"  which  have  prevailed  in  various  por- 
tions of  the  world  at  different  periods.  On  making  a 
comparison,  it  will  be  found  that  all  these  epidemics 
possess  certain  characters  in  common,  although  pre- 
senting occasional  features  of  difference.  If  we  study 
them  together,  it  will  be  also  seen  that  they  are  closely 
connected  b}^  a  bond  of  union  which  is  to  be  found  in 
the  pathological  anatomy  of  the  disease,  and  which  con- 
sists in  a  peculiar  exudation.  This  was  clearly  recog- 
nized by  Bretonneau,  and  is  in  fact  the  dominant  idea 
in  his  memoir  upon  the  subject.  Bretonneau  was  in- 
correct, however,  as  we  have  shown,  in  bringing  together, 
under  the  term  diphtherite,  affections  which  are  se- 
parated by  wide  intervals ;  he  was  wrong  in  supposing 
the  absence  of  all  constitutional  sjnnptoms  in  the  disease 


84  DIPHTHERIA. 

as  also  in  regard  to  the  integrity  of  the  subjacent 
mucous  membrane  on  the  removal  of  the  exudation.  At 
least,  we  can  truly  say  that  his  views  on  these  points  do 
not  coincide  with  what  experience  has  taught  us  within 
the  last  few  years.  So  that,  while  we  give  M.  Breton- 
neau  the  credit  of  having  established  these  two  leading 
facts — viz.,  that  all  the  various  forms  of  epidemic  sore 
throat  which  have  prevailed  in  difierent  parts  of  the 
world  are  identical,  and  that  the  characteristic  of  this 
identity  is  the  existence  of  the  exudation — we  must 
confess  that  his  description  is  wanting  in  many  points 
necessary  to  a  faithful  representation  of  the  disease. 

We  subjoin  portions  of  an  article  by  MM.  Barthez  and 
Eilliet,  contained  in  their  admirable  Traite  des  Maladies 
des  Enfans,  as  also  the  brief  definition  by  Dr.  J.  Copland 
in  his  dictionary  as  being  more  comprehensive  than  the 
description  given  by  M.  Bretonneau. 

"The  angina  described  by  authors  under  the  name  of 
gangrenous,  pseudo-membranous,  coiienneuse,  and  to 
which  M.  Bretonneau  has  applied  the  term  diphtherite, 
is  a  disease  which  principally  attacks  children,  and  the 
character  of  which  has  given  ri^e  to  numerous  discus- 
sions. It  may  occur  as  a  primary  disease  (the  true  diph- 
therite of  Bretonneau),  and  also  as  a  secondarj^  disease, 
supervening  most  commonly  upon  eruptive  fevers. 

" Paiholog leal  Anatomy. — The  uvula,  tonsils,  and  pha- 
rynx are  covered  by  false  membranes  of  greater  or  less 
thickness,  of  a  3^ellow  or  yellowish-white  color,  and  some- 
times gray.     They  exhale  no  fetid  smell  after  death,  and 


NATUKE.  85 

are  generally  very  firmly  adherent  to  tlie  subjacent 
mucous  membrane,  especially  in  tlie  pharynx  and  arch 
of  the  palate.  The  tonsils  are  rarely  covered  with  a 
continuous  layer,  but  spotted  here  and  there  with  patches 
of  various  sizes,  many  of  which  penetrate  into  the  lacunse 
of  these  organs.  In  the  pharynx,  the  false  membrane 
forms  a  large  plate,  a  sort  of  yellow  covering  to  the 
mucous  membrane,  sometimes  continuous,  sometimes 
disposed  in  broken  or  interrupted  layers.  The  false 
membranes  have  sometimes  a  gray  color,  which  led  for 
some  time  to  the  belief  that  they  were  the  result  of  gan- 
grene ;  but  the  gangrenous  aspect  of  the  pharynx  is  due 
to  the  putrid  degeneration  of  the  pellicular  concretions 
themselves. 

''The  exudation  of  blood,  which  is  not  unusual  in 
diphtheritic  inflammation,  completes  the  error.  The 
false  membrane,  colored  by  this  fluid,  successively  as- 
sumes different  tints,  marks  of  its  decomposition. 

''  M.  Bretonneau  maintains  that  the  mucous  membrane 
subjacent  to  the  exudation  for  the  most  part  preserves 
its  usual  consistence  and  appearance.  '  Slight  ecchymo- 
sis,  and  a  trifling  amount  of  erosion  upon  the  surface,  in 
cases  where  the  disease  has  been  of  long  standing,  con- 
stitute the  chief  alterations  in  the  tissues.'  In  some  cases 
which  have  come  under  our  observation  we  have  wit- 
nessed much  more  serious  lesions;  but,  on  the  other 
hand,  we  have  not  met  with  those  lines  of  ecchymosis 
which  are  described  as  being  always  present  in  the 
8 


bb  DIPHTHERIA. 

pharynx  and  upon  the  velum  palati.     In  two  cases  under 
our  care  the  pharynx  was  deeply  ulcerated. 

"The  tumefaction  of  the  submaxillary  glands  is  a 
lesion  which  M.  Bretonneau  considers  as  being  almost 
constant.  They  attain  a  considerable  size,  but  rarely 
suppurate. 

"  SymiUoms,  &c. — Diphtheria  commonly  sets  in  with 
slight  febrile  symptoms,  the  strength  and  appetite  not 
being  sensibly  affected.  The  patient  complains  of  a 
slight  pain  in  the  throat:  no  change  in  deglutition. 
Very  shortly  after  the  first  attack,  a  slight  swelling  of 
the  tonsils  is  observed,  and  frequently  a  little  exudation 
of  false  membrane.  Soon  whitish  or  yellowish-white 
spots  are  seen  on  the  tonsils,  which  extend  to  the  larynx, 
velum  palati,  and  pharynx.  Sometimes  these  are  limited 
to  the  tonsils  and  velum  palati,  when  they  often  lose  the 
white  color,  and  become  of  a  dirty  gray,  giving  out  an 
extremely  fetid  odor ;  an  abundance  of  saliva  is  at  the 
same  time  running  from  the  corners  of  the  mouth.  The 
glands  of  the  neck  gradually  become  enlarged. 

"At  the  end  of  a  certain  time,  according  as  the  mem- 
brane is  more  or  less  adherent,  it  commences  to  separate, 
and  is  thrown  off.  Or,  remaining  adherent  to  the 
mucous  surface,  it  gradually  grows  thinner,  and  thus 
disappears. 

"During  the  course  of  the  disease,  the  appetite  not 
unfrequently  remains  unimpaired.  There  is  neither 
diarrhcea  nor  vomiting.  If  the  disease  terminates  favor- 
ably, there   remains   only   a   slight   redness   about   the 


NATURE.  87 

throat.  In  tlie  fatal  cases,  tlie  inflammation  extends 
from  tlie  fauces  to  the  air-passages,  thus  giving  rise  to 
croup.  Occasionally  the  disease  assumes  a  typhoid 
character,  a  condition  which  has  not  been  observed  by 
M.  Bretonneau.  When  diphtheria  runs  through  its 
course  without  complications,  it  generally  lasts  from  six 
to  nine  days ;  if  croup  intervenes,  it  may  prove  fatal  in 
one  or  two  days." 

Dr.  Copland,  in  his  dictionary,  defines  diphtheria 
as  follows : — 

"  Soreness,  pain,  and  heat  in  the  throat,  often  increased 
on  deglutition ;  redness,  with  an  exudation  of  a  buff  or 
gray-colored  lymph  in  spots  at  an  early  stage,  com- 
mencing either  in  the  fauces,  on  the  tonsils,  or  pharynx, 
and  quickly  extending  to  these,  and  often  also  to  the 
larynx  and  oesophagus;  the  exudation  becoming  more 
continuous  and  firm,  accompanied  with  fever,  and  ap- 
pearing generally  either  epidemically  or  endemically." 

If  we  carefully  examine  the  various  epidemics  of  diph- 
theria, we  shall  be  able  to  bring  them  together  under  two 
principal  forms  of  the  disease — the  mild  and  the  severe. 

The  mild  form  is  usually  preceded  by  more  or  less 
fever,  by  some  loss  of  appetite,  a  slight  difficulty  in 
deglutition,  with,  perhaps,  some  discomfort  about  the 
fauces.  The  tongue  presents  a  thick  whitish  coat.  On 
examination,  at  the  very  outset  of  the  disease,  the  velum 
palati,  uvula,  and  pharynx  are  of  a  bright  red  color. 
The  tonsils  are  slightly  swollen,  and  are  of  the  same  red 
liue.     In  a  short  time,  gcnerallj''  from  twelve  to  thirty- 


88  DIPHTHERIA. 

six  hours  after  the  attack,  upon  one  tonsil,  and  some- 
times upon  both,  are  seen  distinct  white  patches  of  ex- 
udation of  false  membrane.  These  soon  extend  over 
the  uvula  and  posterior  wall  of  the  pharynx.  The  ex- 
udation adheres  more  or  less  firmly  to  the  adjacent 
mucous  surface,  and  cannot  be  easily  removed.  In  a 
few  cases  the  exudation  remains  confined  to  the  tonsils, 
and  neither  grows  black  nor  putrefies.  The  surrounding 
mucous  membrane  is  swollen  and  projecting.  The 
parotid  and  submaxillary  glands  are  not  much  swollen. 

The  duration  of  the  mild  form  of  the  disease  is  from 
six  to  nine  or  ten  days. 

In  the  severe  form,  the  disease  is  ushered  in  by  intense 
headache,  hot  pungent  skin,  rapid  feeble  pulse ;  there  is 
great  difficulty  in  deglutition,  and  the  respiration  is 
much  hurried.  The  tongue  is  covered  with  a  thick, 
dirty  brownish  coat.  On  examination  of  the  throat,  the 
tonsils  are  found  enormously  swollen  and  covered  with 
a  thick  ash-colored  membrane,  which  has  also  extended 
to  the  uvula  and  to  the  posterior  walls  of  the  pharynx, 
and  not  unfrequently  gives  out  a  fetid  odor.  Unless 
arrested  by  treatment,  all  the  symptoms  increase  in 
severity,  the  respiration  becomes  much  oppressed,  there 
is  a  barking  cough,  and  a  change  in  the  voice,  which 
becomes  hoarse  and  indistinct ;  the  deglutition  becomes 
so  painful  that  children  refuse  to  swallow  even  liquids ; 
the  saliva  dribbles  from  the  corners  of  the  mouth,  and 
an  acrid  discharge  flows  from  the  nares.  The  glands  of 
the  neck  are  greatly  swollen  and  tender.     The  patient  i^ 


NATURE.  89 

restless  to  an  extreme  degree,  tossing  about  and  then 
sinking  into  a  semi-comatose  condition.  These  cases, 
when  they  prove  fatal,  as  is  the  general  rule,  terminate 
either  by  rapid  prostration  of  the  vital  powers  or  by  an 
extension  of  the  diphtheritic  membrane  into  the  air- 
passages. 

M.  Trousseau  makes  two  divisions  of  the  disease — ■ 
simple  and  malignant  diphtheria.  In  both,  the  essentials 
of  the  disease  are  the  same.  The  one  may  generate  the 
other,  and  the  most  simple  case  may  give  rise  to  another 
of  the  most  malignant  type. 

Such,  then,  are  the  principal  features  of  diphtheria. 
There  are  some  points,  however,  as  regards  its  nature, 
which  require  to  be  considered  more  in  detail.  First,  the 
characteristics  of  the  false  membrane  itself  claim  our 
special  attention. 

As  regards  the  physical  appearances  of  the  false  mem- 
brane, if  closely  examined  by  the  unaided  sight,  it  has 
the  character  of  a  fibro-plastic  membrane.  In  the  larynx 
it  presents  a  whiter  color  than  when  it  is  situated  in  the 
fauces,  and  very  much  resembles  the  membrane  thrown 
out  in  true  croup,  although  it  is  softer  and  often 
soddened  by  the  sanious  matter  wliich  exudes  from 
beneath  and  around  it. 

Dr.  Jenner  distinguishes  two  varieties  of  diphtheritic 
exudation,  one  of  which  is  very  tough  and  elastic,  and 
as  much  as  one-eighth  of  an  inch  in  thickness,  resembling 
washleather;  the  other,  gray,  pulpy,  or  creamy.  The 
former  consisting  of  such  fibres  as  we  see  in  the  buffy  coat 

8* 


90  DIPHTHERIA. 

of  the  blood  coagula — the  latter,  pus  pjoid  corpuscles  of 
Lebert  and  other  smaller  and  larger  granular  corpuscles, 
epithelium  and  oleo-protein  granules.  Dr.  J.  teaches  that 
these  two  forms  of  concretion  are  severally  related,  the 
latter  with  the  asthenic,  the  former  with  the  so-called 
inflammatory  types  of  the  general  disease.^ 

After  very  long  and  careful  examination,  it  has  been 
observed  that  the  exudation  is  preceded  by  a  sero- 
mucous  transparent  liquid  which  in  some  cases  is  very 
abundant.  This  liquid  once  exuded,  soon  takes  on  more 
density  and  a  closer  adherence  to  the  surface  which 
secretes  it,  and  at  certain  points  becomes  a  little  less 
transparent,  assuming  a  yellowish  tinge.  These  points 
soon  run  together,  coalesce,  and  thus  form  a  very  thin 
pellicle,  which  may  be  regarded  as  the  commencement 
of  the  false  membrane.  In  fact,  this  commencement  of 
the  false  membrane  is  an  act  of  coagulation,  according  to 
M.  Empis,  which  takes  place  by  a  precipitation  of  fibrin 
independently  of  any  agency  of  the  living  tissue.  This 
is  to  be  seen  most  distinctly  in  the  air-passages,  particu- 
larly in  the  larynx  and  trachea,  in  which  the  tubular 
cast  is  seldom  ever  adherent,  and  is  commonly  much 
smaller  than  the  cavity  it  occupies ;  its  external  surface, 
therefore,  being  separated  by  a  considerable  interval 
from  the  mucous  membrane. 

That  coagulation  is  not   determined   by  the  mucous 
membrane  is,  in  fact,  shown   by  the  experience  of  M. 

'  Britislt  and  Forei'ni  Med.-CLir.  Review,  1802. 


NATURE.  91 

Empis'  in  cases  where  tracheotomy  has  been  performed 
upon  children.     He  says : — 

''At  the  end  of  a  few  hours  after  the  operation  of 
tracheotomy,  whatever  care  might  be  taken  to  clear  the 
canula,  the  instrument  was  seen  to  be  lined  with  a  layer 
of  whitish  concretions,  the  thickness  of  which  continually 
increased.  These  concretions  were  evidently  only  the 
result  of  the  coagulation  of  the  liquid  by  which  the  sides 
of  the  canula  were  constantly  covered." 

The  pellicle  thus  formed,  which  we  said  may  be  con- 
sidered as  the  first  des^ree  of  the  false  membrane,  is 
thicker  at  the  centre  than  at  the  circumference,  and 
generally  may  be  easily  lifted  up,  although  in  very 
small  pieces,  owing  to  its  friability.  Beneath  this  super- 
ficial pellicle,  according  to  M.  Empis,  there  is  still  an 
exudation  of  sero-mucous  matter  which  gradually 
coalesces  with  the  pellicle  already  formed,  thus  pro- 
ducing a  false  membrane  several  lines  in  thickness,  and 
adhering  very  closely  to  the  subjacent  surface. 

In  many  cases  the  membrane  thus  formed  appears  to 
remain  for  some  time  stationary,  and  then  sooner  or  later 
it  takes  on  an  increase  in  thickness  as  well  as  in  extent 
of  surface.  The  secretion  of  sanious  fluid  which  embues 
and  softens  the  concretions  is  also  augmented,  becomes 
yerj  dark  colored,  and  exhales  a  fetid  odor  similar  to 
that  of  gangrene.  This  especially  applies  to  the  deeper 
j)ortions  of  the  fauces,  to  the  vulva,  and  to  the  anterior 
parts  of  the  vagina. 

'  Arch.  Gen.  de  Med.,  Fevrier,  1850. 


92  DIFHTHEKIA. 

With  regard  to  the  cicatrization  of  the  subjacent  sur- 
face^  and  to  the  disappearance  of  the  false  membrane,  M. 
Empis^  says : — 

"We  never  see  the  membrane  disappear  all  at  once, 
leaving  in  its  place  a  cicatrized  surface,  as  is  the  case 
with  an  ordinary  eschar,  but  it  is  by  a  gradual  process 
that  the  pellicle  diminishes  in  thickness,  in  proportion  as 
the  edges  of  the  abraded  surface  cicatrize.  If,  however, 
we  modify  the  secreting  surface  by  an  energetic  local 
treatment,  we  can  cause  the  complete  disappearance  of 
the  membrane,  leaving  nothing  beneath  but  a  granulat- 
ing surface  of  a  healthy  character." 

The  exudation  is  sometimes  situated  upon  the  cuta- 
neous surface,  at  other  times  upon  the  mucous,  and  not 
■unfrequently  upon  both  at  once.  Any  portion  of  the 
external  surface  of  the  body  may  become  the  seat  of  a 
diphtheritic  false  membrane,  the  onlj^  condition  essen- 
tial being  the  absence  of  the  epidermis,  the  skin  thereby 
approximating  to  the  condition  of  a  mucous  membrane. 
This  cutaneous  diphtheria  has  been  much  more 
prevalent  in  certain  epidemics  than  in  others,  especially 
in  France.  In  some  the  cutaneous  affection  has  been  so 
frequent  as  to  become  the  prominent  characteristic  of  the 
disease.  Leech-bites,  blistered  surfaces,  excoriations  of 
any  part,  various  wounds,  in  the  progress  of  an  epidemic, 
might  become  the  seat  of  diphtheritic  inflammation. 
Whatever  may  be  the  situation  of  the  exudation,  it  has 
been  incontestably  proved  that  the  diphtheritic  affections 

'  Arch.  Gen.  de  Med.,  1850. 


'     NATURE.  93 

of  the  skin  are  identical  in  their  nature  with  those  which 
are  seated  in  the  mucous  membrane  of  the  fauces  and 
larynx.  Nor  is  the  external  manifestation  of  the  diph- 
theritic poison  in  any  way  less  formidable  than  the 
faucial.  In  many  cases  reported  by  M.  Trousseau,  the 
symptoms  of  low  typhoid  were  present ;  they  often  ter- 
minated fatally,  or  were  followed  by  a  long  tedious  con- 
valescence. 

When  a  wound  is  attacked  by  diphtheritic  inflamma- 
tion, it  becomes  painful,  fetid,  and  discolored  serosity 
pours  from  it  in  abundance,  and  a  gray  soft  coating  soon 
covers  it  with  a  layer  of  increasing  thickness ;  the  edges 
swell  and  become  violet.  The  wound  remains  often 
obstinately  stationary  for  months ;  sometimes  it  spreads ; 
then  an  erysipelatous  blush  is  seen  around  it ;  pustules 
form,  become  confluent,  burst,  and  leave  apparent  a  diph- 
theritic patch,  which  spreads  ^ven  from  the  head  to  the 
loins. 

A  curious  fact  which  has  been  observed  as  regards 
the  seat  of  the  diphtheritic  exudation,  is,  that  although  it 
is  found  equally  in  the  mouth,  on  the  soft  palate,  the  ton- 
sils, the  pharynx,  the  nasal  foss^,  the  larynx,  trachea, 
and  even  in  the  bronchial  tubes,  on  the  conjunctiva,  the 
vulva  and  anus,  and  upon  the  skin,  it  is  not  found  upon 
those  portions  which  are  removed  from  the  contact  of 
the  air;  these  seem  refractory  to  the  extension  of  the 
disease.  M.  Empis^  remarks,  that  he  never  saw  true 
diphtheria  extend  into  the  oesophagus,  while,  on  the  con- 

*  Arcli.  Geu.  de  Med. 


91  DIPHTnERTA. 

trary,  the  exudation  of  certain  aphthous  affections  show 
a  great  tendency  to  spread  into  the  oesophagus,  but  never 
into  the  respiratory  organs.  The  atmosphere  would  thus 
certainly  seem  to  exert  an  influence  in  promoting  diph- 
theritic inflammation.  The  same  observations  have  been 
made  by  M.  Isambert/  as  well  as  by  others. 

Mr.  Smith  directs  the  attention  of  the  profession  to  an 
affection  which  in  many  respects  resembles  diphtheria, 
but  which  differs  from  it  essentially  both  in  its  nature 
and  its  results.  He  gives  the  following  as  the  charac- 
teristics of  spurious  diphtheria:  The  patient  usually  com- 
plains, first  of  a  curious  feeling  in  the  throat,  as  if  a  pin 
were  pricking  it ;  there  is  languor  with  pains  in  the  back 
and  legs  ;  and  sometimes  considerable  tenderness  on  pres- 
sure on  the  outside  of  the  throat,  just  under  the  angle  of 
the  jaw. 

The  tonsils  and  uvula  are  more  or  less  tumefied,  and  of 
an  angry  red  color,  while  on  their  surface  there  are 
small,  irregularly  shaped  yellowish  white  spots.  These, 
however,  are  evidently  of  an  aphthous  nature — there 
may  be  only  one  or  two  on  the  tonsil  or  on  the  uvula,  or 
they  may  be  very  numerous.  However  great  their 
number  may  be,  their  edges  do  not  coalesce;  each  spot  is 
isolated.  They  never  look  excavated,  but  seem  as  if 
they  just  floated  on  the  mucus  which  moistens  the 
throat. 

The    appearance    of    the    tongue    usually    indicates 

•  Ai-cliiv.  Gen.  de  Me.l.,  1S57. 


NATURE.  95 

derangement  of  tlie  digestive  organs,  and  the  pulse 
is  smaller  and  more  frequent  tlian  in  health. 

The  treatment  of  spurious  diphtheria  is  exceedingly 
simple ;  a  mild  aperient — 10  or  15  drops  of  the  tincture 
of  the  muriate  of  iron,  three  times  a  day,  with  a  simple 
gargle  of  chlorine  water,  will  be  sufficient.  The  use  of 
stimulants  and  a  liberal  diet  will  remove  the  prostration 
and  muscular  debility  which  may  follow  after  an  attack 
of  this  disease.  Spurious  diphtheria  never  proves  fatal. 
Though  accompanied  with  debility,  it  is  not  followed  by 
paralysis  or  albuminuria ;  a  patient  who  has  suS'ered  from 
this  afiection  may  afterwards  have  true  diphtheria.  The 
affection  seems  to  be  most  common  among  young 
females.^ 

In  order  to  determine  the  value  of  the  exudation  as  a 
characteristic  of  diphtheria,  it  is  well  known  that  M. 
Bretonneau  made  numerous  experiments  relating  to  the 
effects  produced  by  the  application  of  irritant  substances 
to  the  mucous  membrane.  As  the  result  of  these  experi- 
ments, he  found  that  no  substance  was  capable  of 
producing  similar  effects  excepting  cantharides.  He 
says:— 

'•'  The  action  of  the  oil  of  cantharides  when  applied  to 
the  surface  of  the  tongue  and  lips  is  almost  instantaneous. 
In  less  than  thirty  minutes  the  epidermis  shrivels  and 
becomes  raised  and  detached.  It  is  soon  replaced  by  a 
concrete  pellicle,  at  first  thin  and  semi-transparent,  which 
speedily  becomes  more  opaque  and  thicker.     Like  the 

•  Edinburgh  Med.  Journal,  Nov.  1863. 


96  DIPHTHERIA. 

diphtheritic  exudation,  this  membrane,  which  is  at  first 
slightly  adherent,  is  detached  and  reproduced  with  great 
readiness.  Within  a  period  of  six  or  seven  days  it  may 
be  several  times  renewed." 

M.  Bretonneau  concludes,  from  these  experiments, 
that  the  membrane  of  cantharides  is  anatomically  iden- 
tical with  that  of  diphtheria,  and  is,  therefore,  forced  to 
admit  that  diseases  cannot  be  distinguished  merely  by 
their  anatomical  characters.^ 

''The  facts  relating  to  the  cantharidic  inflammation  do 
not  in  the  slightest  degree  weaken  the  specificity  of  diph- 
theria; on  the  contrary,  if  we  consider  them  in  their 
true  light  and  in  their  complete  development,  they  prove 
it  experimentally  and  demonstratively.  However  close 
may  be  the  resemblance  between  the  two  forms  of  inflam- 
mation, they  are  distinguished  by  well-marked  charac- 
ters. The  cantharidic  inflammation  is  limited  to  the 
surfaces  which  have  been  subject  to  the  inflaming  action 
of  the  vesicant,  and  soon  become  extinct ;  while  it  is  in 
the  nature  of  the  diphtheritic  inflammation  to  extend 
and  to  persist." 

"  With  the  view  of  determining  how  far  the  act  of 
fibrinous  concretion  may  be  considered  a  consequence 
of  the  anatomical  or  physiological  peculiarities  of  the 
structure  affected,  independently  of  the  constitutional 
state,  or  of  the  morbid  condition  of  the  blood  arising 
from  the  disease,  I  made  the  following  experiments :  I 

'  Traits  de  la  Diplitherite,  p.  367. 


NATURE.  97 

injected  into  the  air-passages  of  several  dogs  small 
quantities  of  a  solution  of  cantharides  in  olive  oil,  and 
examined  tlie  consequent  alterations  of  tlie  mucous 
membrane  after  various  periods.  Two  liours  after  the 
introduction  of  the  solution,  it  was  found  that  the 
mucous  surface  of  the  larynx  was  scattered  over  with 
patches  scarcely  perceptibly  redder  than  the  surround- 
ing membrane,  and  that  that  structure  was  covered 
co-extensively  with  those  patches,  with  a  gelatinous 
covering  of  tolerably  firm  concretion,  differing  from 
that  of  diphtheria  only  in  its  greater  transparency — a 
character,  probably,  mainly  attributable  to  the  absence 
of  lamination — arising  from  its  simultaneous  formation. 
This  concretion  possesses  a  structure  which  is  identical 
with  that  of  the  early  condition  of  diphtheria,  consisting 
of  a  fibrinous  matrix  or  substratum,  in  some  parts  of 
which  cells  are  imbedded.  The  substratum  appears  on 
microscopic  examination  to  be  transparent  and  faintly 
granular,  but  sometimes  exhibits  indistinctly  the  cha- 
racters of  fibrillation The  cell  wall  is  of 

extreme  delicacy,  and  incloses  a  spheroidal  nucleus, 
distinguishable  without  the  addition  of  acetic  acid. 
(Fig.  2.)  On  the  addition  of  that  re-agent,  the  former 
becomes  distended  but  does  not  disappear,  while  the 
latter  either  assumes  the  form  of  a  spheroidal  highly 
refractive  body  or  is  resolved  into .  the  double,  triple, 
or  horse-shoe  shaped  forms  often  described  as  char- 
acteristic of  the  pus-corpuscle.  On  examining  the 
mucous  membrane  subjacent  to  the  concretion,  it  was 
9 


98  DIPHTHERIA. 

found  to  have  lost  its  columnar  or  ciliated  epithelium, 
but  the  cells  of  the  subjacent  epithelial  layer  existed  in 
an  unaltered  condition.  They  differed  so  completely  in 
appearance,  size,  and  structure,  from  the  exudation  cells. 

Fig.  2. 


After  Sauderson. 

that  there  was  no  difficulty  whatever  in  distinguishing 
them.  In  two  daj^s  the  process  of  transformation  of  the 
substance  of  the  concretion  into  fibrous  tissue  had  com- 
menced. The  pellicle  possessed  great  firmness  and 
ehxsticity,  and  could  be  stripped  ofi"  the  affected  patches 
with  ease  to  any  extent. 

"  Of  these  facts,  I  will  not  further  comment  than  to 
observe  that  the  only  important  difference  between  the 
cantharidic  and  the  diphtheritic  concretion,  consists  in 
the  absence  of  any  tendency  in  the  latter  to  transforma- 
tion into  permanent  tissue,  as  contrasted  with  the  early 
period,  at  which  that  process  commences  in  the  former. 
So  far  as  concerns  this  mere  fact  of  fibrinous  concretion, 
we  are  perhaps  entitled  to  infer  that  it  indicates  nothing 
more  than  the  intensity  of  the  process  of  exudation ; 


NATURE.  99 

and  that  in  diphtheria,  the  subsequent  changes  are  pre- 
vented or  retarded  either  by  a  morbid  modification  of 
the  fibrin  itself,  or  bj  an  abnormal  condition  of  the 
adjacent  living  structures."  (Sanderson  on  Diphtheritic 
Sore  Throat.  Brit,  and  For.  Med.-  Chir.  Review,  Jan.  1860, 
pp.  181-9.) 

Under  the  microscope  the  false  membrane  of  diph- 
theria exhibits  the  ordinary  elements  of  such  structures, 
although  its  characters  appear  to  vary  somewhat.  The 
elements  usually  detected  are,  chiefly,  molecular  par- 
ticles, matted  epithelium-cells  of  all  kinds  and  shapes, 
pus,  and  blood- cells.  These  are  arranged  in  layers,  and 
united  so  as  to  form  a  membranous  deposit. 

Dr.  J.  Darrack  states  that  he  had  examined  a  num- 
ber of  the  patches  of  the  membrane,  which  were  care- 
fully removed  during  life,  and  some  after  death.  The 
elements  found  in  all  these  examinations,  were  cells — 
young  epithelial  nuclear  bodies,  not  affected  by  acetic 
acid,  and  m.ost  likely  aborted  epithelial  cells,  w^ith  pus 
corpuscles  and  granular  matter — the  granules  occasion- 
ally assuming  a  disposition  to  form  themselves  into 
parallel  lines.  In  no  one  case  could  be  perceived  a 
distinct  fibrillation  as  is  easily  recognized  in  the  transu- 
dations, upon  the  pericardium  and  other  serous  mem- 
branes. It  is  true  that  a  granular  form  of  fibrin  has 
been  described,  but  this  has  not  been  established.' 

M.  Empis  has  particularly  investigated  the  pathologi- 
cal anatomy  of  the  disease  by  the  aid  of  the  microscope. 

'  American  Jouraal  of  Med.  Sciences,  1861. 


100  DIPHTHERIA. 

Now,  it  is  well  known  that  some  observers,  among  whom 
we  may  mention  Yogel  and  Dr.  Lajcock,  have  associated 
with  the  disease  the  presence  of  a  parasitic  fungus  which 
fixes  itself  on  the  mucous  membrane  of  the  fauces,  and 
is  thought  to  be  the  starting-point  of  the  vascular  con- 
dition of  which  we  have  spoken,  which  afterwards  gives 
rise  to  the  exudation.  This  parasitic  fungus  is  the 
oidium  albicans. 

M.  Empis,  after  noticing  the  statement  of  Yogel,  that 
the  oidium  albicans  is  to  be  found  in  the  pellicle  of  diph- 
theria, says : — 

"This  author  has  evidently  confounded  under  the 
term  diphtherite  all  the  pseudo-membranous  exudations, 
without  examining  into  their  nature  or  characters,  for 
this  parasite  is  not  found  in  the  true  diphtheritic  or 
fibrinous  exudations,  but  only  in  those  of  muguet." 

He  then  goes  on  to  compare  the  diphtheritic  exuda- 
tion with  other  similar  products,  such  as  the  buffy  coat 
of  the  blood,  the  false  membrane  of  pleurisy,  the  exuda- 
tion of  blistered  surfaces,  and  that  which  occurs  in  the 
scarlatinal  sore  throat,  and  arrives  at  these  conclusions : 
That  it  is  easy  to  determine,  by  means  of  the  micro- 
scope— 1st,  the  pseudo-membranous  exudations  of 
muguet,  which  have  nothing  in  common  with  other 
false  membranes ;  2d,  the  buffy  coat  of  the  blood ;  3d, 
the  false  membrane  of  pleurisy ;  but  that  it  is  impossible 
to  draw  any  distinction,  founded  on  microscopic  investi- 
gation, between  the  exudation  of  diphtheria  and  that  of 


NATURE.  101 

the  blistered  surface,  or  tliat  which  occurs  in  the  angina 
of  scarlatina. 

As  the  development,  then,  of  this  parasitic  growth 
takes  place  in  a  variety  of  other  diseases,  we  must  regard 
it  as  purely  accidental,  or  at  least  secondary,  and  by  no 
means  as  characteristic,  or  an  exciting  cause  of  the 
disease  under  consideration. 

The  communication  of  Dr.  Lay  cock  also  fails  to  in- 
spire us  with  that  confidence  in  his  theory  which  it 
would  perhaps  have  done,  had  the  case  been  one  of 
uncomplicated  diphtheria.  Moreover,  he  himself  also 
admits  that  this  parasite  is  discoverable  in  the  patches 
of  aphthae  as  w^ell  as  in  the  secretions  of  the  mouth  in 
other  diseases. 

In  an  excellent  communication  to  the  Medical  Times 
and  Gazette,'^  Dr.  Wilks  says : — 

"Opinions  still  vary  as  to  the  true  nature  of  diph- 
theria, and  therefore  as  to  its  connection  with  a  parasite 
fungus  (o'idium  albicans).  As  on  several  occasions  the 
white  film  on  the  throat  has  been  found  to  consist  of 
this  fungus,  it  has  been  conjectured  w^hether  the  malady 
is  not  one  having  a  parasitic  origin,  and  the  belief  has 
been  rendered  more  probable  from  the  fact  that  several 
new  diseases  have  of  late  prevailed  throughout  the 
organic  kingdom,  both  animal  and  vegetable,  which  are 
clearly  traceable  to  parasites— for  example,  the  oidium 
of  the  vine.  ... 

'  October  2,  1858. 

9* 


102  DIPHTHERIA. 

"My  attention  being  directed  to  tliis  matter,  I  took 
tlie  opportunity  to  examine  the  films  which  occasionally 
form  on  the  mouths  of  those  sick  with  various  diseases ; 
and  on  submitting  them  to  the  test  of  the  microscope, 
felt  some  surprise  in  witnessing,  in  all,  fungous  growths, 
which  I  have  not  been  able  to  distins^uish  from  that  of 
diphtheria." 

After  giving  a  brief  history  of  several  cases  of  differ- 
ent diseases,  in  all  of  which  either  a  distinct  pellicle  or  a 
thick  secretion  was  present.  Dr.  Wilks  says : — 

"These  facts  are  sufficient  to  show  that  a  vegetable 
fungus  may  spring  .up  on  the  buccal  mucous  membrane 
in  various  cases  of  disease,  but  requiring  probably  some 
previously  morbid  condition  for  a  nidus.  Is  it  not  so  in 
diphtherite?  Is  the  disease,  strictly  speaking,  a  malig- 
nant sore  throat,  and  the  formation  of  a  pellicle  an  acci- 
dent, or  is  the  latter  an  essential  part  of  the  affection  ? 

"In  speaking  of  the  parasitic  growth  found  in  the 
above-mentioned  instances,  we  are  aware  of  the  objection 
which  can  be  made — that  the  fungus  of  diphtheria  is 
peculiar  (supposing  it  always  to  be  present),  and  that 
found  in  the  mouth  of  other  sick  persons  is  in  connec- 
tion with  aphthoe,  and  is  another  variety.  In  answer,  I 
can  only  say  that  I  failed  to  discover  in  the  above  cases 
any  difference,  and,  moreover,  the  chai^acter  of  the  pelli- 
cle, and  its  rapid  extension  over  the  whole  mouth,  throat, 
and  tongue,  was  totally  unlike  ordinary  aphtha3." 

Dr.  Wade,  of  Birmingham,  considers  that  there  is 
present  in  some  cases,  \ipoy  near  the  exudation  of  diph- 


CONTAGION.  103 

theria,  a  fungous  growth — not,  however,  the  oidium 
albicans,  but  the  leptothrix  buccalis,  such  as  is  so  com- 
monly met  with  in  the  mouth  and  phar3^nx.  Further 
investigations,  however,  have  shown  that  the  presence 
of  either  of  these  parasitical  growths  is  to  be  considered 
as  a  mere  accident,  and  not  an  essential  part  of  the  affec- 
tion. In  conclusion,  we  may  say  that  the  distinguishing 
character  of  the  diphtheritic  exudations,  and  that  which 
separates  them  from  other  forms  of  exudation,  is,  "  that 
they  have  the  power  of  organization,  and  never  become 
vascular.  Hence  they  never  concur  in  the  reparation  of 
tissue,  but  putrefy  on  the  su.rface  if  they  be  not  removed, 
existing  always  as  a  foreign  body." 

Is  Diphtheria  Infectious  ? — Upon  this  point,  as  we 
might  naturally  suppose,  there  is  a  wide  difference  of 
opinion.  M.  Bretonneau  maintained  that  the  exudation 
of  diphtheria  possessed  a  special  virulence,  and  that  the 
disease  may  be  not  only  propagated  by  the  application 
of  the  secretion  from  an  affected  surface  to  sound  parts, 
after  the  manner  of  smallpox,  but  that,  like  syphilis, 
diphtheria  cannot  be  communicated  from  a  diseased 
to  a  healthy  person  in  any  other  way.     He  says : — 

"  Innumerable  facts  have  proved  that  those  who  attend 
patients  cannot  contract  diphtheria  unless  the  diphthe- 
ritic secretion  in  the  liquid  or  pulverulent  state  is  placed 
in  contact  with  the  mucous  membrane,  or  with  the  skin 
on  a  point  denuded  of  epidermis,  and  this  application 
must  be  immediate. 


104  DIPHTHERIA. 

''The  'Egyptian  disease"  is  not  communicated  by 
volatile  invisible  emanations,  susceptible  of  being  dis- 
solved in  tlie  air,  and  of  acting  at  a  great  distance  from 
their  point  of  origin.  It  no  more  possesses  this  quality 
than  the  syphilitic  disease.  If  the  liquid  which  issues 
from  an  Egyptian  chancre,  as  visibly  as  that  which  pro- 
ceeds from  a  venereal  chancre,  has  seemed  under  certain 
circumstances  to  act  like  some  volatile  forms  of  virus, 
the  mistake  has  arisen  from  its  not  having  been  studied 
with  sufficient  attention.  The  appearance  has  been 
taken  for  the  reality."^ 

In  support  of  his  opinion,  M.  Bretonneau  has  collected 
a  few  cases.  One  is  that  of  M.  Herpin,  who  was  surgeon 
to  the  hospital  at  Tours.  A  child  attacked  with  diph- 
theria, who  had  also  transmitted  the  affection  to  its 
nurse,  was  placed  under  his  care.  Upon  visiting  it  one 
day,  and  during  the  process  of  sponging  the  pharynx,  in 
a  paroxysm  of  cough,  a  portion  of  the  diphtheritic 
matter  was  ejected  from  the  mouth,  and  lodged  in  the 
aperture  of  the  nostril  of  M.  Herpin.  This  he  neglected 
to  remove,  and  the  consequence  was  a  severe  diphtheri- 
tic inflammation  which  spread  over  the  whole  nares  and 
pharynx.  The  constitutional  symptoms  were  extremely 
severe,  and  the  prostration  so  great,  that  conva- 
lescence occupied  more  than  six  months.^  Dr.  Gendron, 
of  Chateau  de  Loire,  received  on  his  lips  portions  of 

'  Considered  by  Bretonneau  as  identical  with  diphtheria. 

2  Traite  de  la  Diphtherite. 

*  Arch.  Grt-nerales  de  Med.,  Jan.  1804. 


CONTAGION".  105 

diphtheritic  exudation,  expelled  by  a  patient  during  a 
fit  of  coughing.  Laryngeal  inflammation  came  on  with 
much  violence,  but  his  life  was  saved  by  prompt  and 
decided  measures. 

In  1826,  M.  Bretonneau  was  summoned  to  the  Ecole 
Militaire,  in  which  diphtheria  was  prevailing;  although 
many  cases  of  the  disease  occurred,  none  proved  fatal 
after  his  arrival.  He  states,  however,  that  a  boy  affected 
with  frost-bite  of  his  foot,  happening  to  use  a  bath  that 
had  been  employed  for  a  diphtheritic  patient,  became 
the  subject  of  painful  diphtheritic  exudation  on  the  great 
toe. 

M.  Lespiea'  also  gives  an  account  of  a  soldier  who, 
during  the  epidemic  of  the  disease  at  Avignon,  used  the 
teaspoon  of  a  diphtheritic  patient,  and  in  consequence 
contracted  the  disease  in  his  mouth ;  and  of  another,  who 
was  attacked  with  diphtheria  the  night  after  sleeping 
with  a  patient. 

Similar  cases  have  been  cited  by  authors  in  favor  of 
the  theory  of  contagion  by  inoculation.  On  the  other 
hand,  Prof.  Trousseau  failed  in  experiments  which  had 
in  view  the  inoculation  of  himself  and  two  of  his  pupils 
with  diphtheritic  matter,  and  Dr.  Harley,  of  London,  was 
not  more  successful  in  similar  experiments  on  various 
animals. 

M.  Bretonneau  goes  so  far  as  to  maintain  that  the 
facts  which  he  relates,  and  other  details  in  his  possession, 

'  Memoires  de  Med.  et  Chirurgie  Militaire,  Paris,  1854. 


106  DIPHTHERIA. 

corroborate  the  assertion  that  the  atmosphere  cannot 
convey  the  contagion  of  diphtheria,  Avhich  is  only  trans- 
missible by  inoculation.  This  opinion,  however,  is  not 
supported  by  the  experience  of  other  writers,  neither 
does  it  accord  with  the  facts  deduced  from  recent  epi- 
demics. In  fact,  it  may  be  very  clearly  shown  from  the 
evidence  already  collected,  that  contagion  plays  the 
principal  part  in  the  propagation  of  diphtheria. 

M.  Isambert,^  in  his  paper  upon  the  epidemic  of  malig- 
nant sore  throat,  which  occurred  in  Paris  in  1855,  gives 
the  following  as  his  experience : — 

"Diphtheritic  affections  sometimes  appear  sporadi- 
cally ;  they  also  often  seem  to  be  endemic,  as  wxll  as 
epidemic  and  contagious.  As  predisposing  causes,  we 
may  consider  that  the  lymphatic  temperament,  a  feeble 
constitution,  privation,  &c.,  all  exert  a  decided  influence. 
Youth  is  much  more  exposed  to  the  .disease  than  any 
subsequent  age.  Locality  and  overcrowding  have 
a  positive  effect ;  so  also  do  cold  and  changeable  seasons. 

"Epidemic  influences  are  much  the  most  powerful. 
As  to  the  contagious  nature  of  the  disease  there  can  be 
no  doubt,  since  many  physicians  have  contracted  the  dis- 
ease. The  opinion  of  M.  Bretonneau  that  diphtheria  is 
not  transmitted  by  the  atmosphere,  but  is  always  the 
result  of  inoculation,  is  altogether  too  exclusive.  With 
M.  Trousseau,  we  cannot  reject  infection  at  a  distance  as 
one  of  the  means  of  propagation  possessed  by  diphthe- 
ria." 

'  Archives  GC-uerales  de  MOd.,  1850. 


CONTAGION.  107 

With  regard  to  tlie  influence  exercised  by  the  moist- 
ure of  the  air,  by  the  temperature,  and  by  the  particukr 
locality,  M.  Trousseau  thus  expresses  himself: — 

"In  the  villages  of  the  Loire,  remarkable  for  their 
salubrity  and  for  their  excellent  position,  I  have  seen 
diphtheria  prevail  to  a  terrible  extent,  while  the  villages 
of  Sologne,  situated  in  the  midst  of  marshes,  remained 
exempt ;  and,  again,  hamlets  bordering  upon  ponds 
depopulated ,  by  the  epidemic,  while  others  enjoyed  a 
complete  immunity." 

The  observations  of  M.  Empis  lead  him  to  favor  the 
idea  of  contagion.  AYhile  at  the  same  time  he  recog- 
nizes, as  a  character  of  diphtheria,  "  the  property  which 
it  has  of  being  generalized  in  the  economy,  like  the  dis- 
eases totius  suhstantise ;"  a  property  which,  as  he  observes, 
may  be  best  appreciated  when  the  disease  is  studied  epi- 
demically. 

Carnevale  and  M.  Aurelius  Severinus,  as  well  as  Fran- 
ciscus  Kola,  admit  the  contagious  properties  of  diph- 
theria, as  well  as  almost  all  the  writers  upon  the  subject 
of  the  sevententh  century. 

Dr.  Samuel  Bard,  as  we  have  before  remarked,  con- 
sidered the  "suffocative  angina"  which  he  describes,  as 
infectious. 

"  The  disease  I  have  described,  appeared  to  me  to  be 
of  an  infectious  nature,  and  as  all  infection  must  be 
owing  to  something  received  into  the  body,  this,  there- 
fore, whatever  it  is,  being  drawn  in  by  the  breath  of  a 
healthy  child,  irritates   the   glands   of  the   fauces   and 


1U8  DIPHTHERIA. 

trachea  as  it  passes  by  them,  and  brings  about  a  change 
in  their  secretions.  The  infection,  however,  did  not 
seem,  in  the  present  case,  to  depend  so  much  on  any 
generally  prevailing  disposition  of  the  air  as  upon 
effluvia  received  from  the  breath  of  infected  persons. 
This  will  account  why  the  disorder  should  go  through  a 
whole  family  and  not  affect  the  next-door  neighbor." 

To  come  now  to  the  observations  of  more  recent 
writers  upon  this  point,  we  may  cite  the  reniarks  of  Dr. 
Banking  in  his  admirable  lectures  on  diphtheria,^  to 
which  we  have  already  alluded  : — 

"  My  own  conviction  is,  that  it  is  infectious  to  a  limit- 
ed degree;  by  which  I  mean  that  when  patients  are 
accumulated  in  small,  ill- ventilated  rooms,  the  disease 
is  likely  to  be  communicated ;  but  I  do  not  fear  that, 
like  scarlatina  or  erysipelas,  it  may  be  propagated  in 
spite  of  all  sanitary  precautions,  still  less  that  the  infection 
can  be  conveyed  by  the  clothes  or  persons  of  those  who 
visit  or  superintend  the  patients.  That  it  commonly 
spreads  through  the  family  once  invaded  is  to  be 
attributed,  in  some  degree,  to  the  persistence  of  the  same 
cause  as  originated  the  first  case.  What  that  cause  is,  it 
is  difficult  to  determine. 

.  .  .  .  '^  Stench  and  poverty  and  crowded  rooms 
have  ever  been  the  sad  heritage  of  the  agricultural 
laborer,  but  diphtherite  is  only  of  recent  origin. 
Doubtless  these  insanitary  adjuncts  to  a  laborer's  life 
predispose  him  and  his  children  to  the  assaults  of  any 

'  Lancet,  Jan.  15,  1857. 


CONTAGION.  109 

epidemic  malady,  but  the  true  and  specific  cause  of  diph- 
theria is  a  something  superadded,  and  which  our  senses 
cannot  appreciate." 

In  an  article  by  Dr.  Edward  Ballard,  of  Islington 
{Med.  Times  and  Gaz.,  July  23,  1859),  the  following  facts 
are  given  in  support  of  the  infectious  character  of  diph- 
theria as  it  came  under  his  own  observation : — 

"1.  Infectious  diseases  habitually  spread  in  families 
they  invade.  Out  of  47  families  there  were  only  15  in 
Avhich  the  other  members  all  remained  healthy.  Of 
course  it  may  be  argued,  in  opposition,  that  all  the  mem- 
bers of  a  family  are  equally  exposed  to  the  operation  of 
local  causes  of  disease. 

"  2.  As  a  rule,  it  spread  in  the  houses  it  invaded  chief- 
ly among  those  members  of  the  several  families  who 
were  most  closely  in  communication. 

"3.  In  no  case  where  separation  from  the  sick  person 
has  been  effected  early  in  the  disease,  have  I  noticed 
that  it  has  spread  to  the  separated  individuals.  In  one 
case  where  communication  had  been  allowed  for  three 
days  before  separation,  a  child  was  seized  with  diphthe- 
ria on  the  sixth  day  of  removal  from  home. 

''  4.  The  following  special  instances  (of  which  we  give 
one)  may  be  adduced  of  communication  of  the  disease 
from  one  house  to  another  : — 

"Jane  J.,  set.  10  years,  resided  at  Islington,  with  her 

mother,  an  aunt,  and  three  sisters.     On  May  1st  and  2d 

she  was  on   a  visit   at   the   house  of  an   uncle,  whose 

daughter,  Jane's  cousin,  was  kept  at  home  because  she 

10 


110  DIPHTHERIA. 

was  believed  to  have  a  cold.  On  the  2d;  this  child  ex- 
hibited decided  symptoms  of  diphtheria ;  the  attack  was 
slight  and  she  recovered. 

"On  May  6th,  a  servant  in  this  house  was  taken  ill 
with  a  severe  attack  of  diphtheria,  and  was  removed  to 
St.  Bartholomew's  Hospital,  where  she  died.  On  the  2d; 
Jane  returned  home,  was  taken  ill  on  the  third  with 
diphtheria  in  a  severe  form,  and  died  on  May  9th.  Iler 
mother  and  a  sister,  aged  fourteen  years,  were  both  taken 
ill  on  May  11th.  She  had  not  been  so  much  with  her 
daughter  as  other  members  of  the  family  up  to  the  Sth, 
when  she  sat  up  with  her  all  night.  The  tonsil  sloughed, 
and  there  was  a  complete  cast  of  the  trachea  expectora- 
ted. She  died  on  the  18th.  The  sister,  who  was  also 
attacked  on  the  11th,  slept  v/ith  her  mother,  and,  when 
not  at  school,  was  continually  in  and  out  of  Jane's  room, 
sitting  there  sometimes  for  hours  together.  She  died  on 
May  14th,  asphyxiated.  Another  elder  sister,  who  slept 
with  Jane  and  the  aunt,  suffered  from  nothing  but  a 
slight  sore  throat." 

The  results  of  inquiries  instituted  at  fifty-seven  houses 
where  fatal  cases  occurred,  with  respect  to  local  causes  of 
disease,  were  as  follows : — 

"  In  more  than  half  the  houses,  then,  which  were  ex-  ■ 
amined  there  was  some  defect  or  other  in  the  sanitary 
arranocements  or  in  the  surroundino;  conditions  of  the 
patients.  In  the  greater  number  of  the  houses  thus  defi- 
cient, the  fault  was  discovered  in  the  state  of  the  drain- 
age." 


CONTAGION.  Ill 

Some  writers  of  experience  maintain  that  diphtheria 
possesses  no  contagious  properties  whatever,  and  others 
accord  to  it  but  comparatively  feeble  influence  in  this 
respect. 

M.  Daviot,'  in  a  memoir  on  diphtheria^  says: — 

"  Pharyngeal  diphtheria  is  purely  and  simply  an  epi- 
demic disease.  Like  other  diseases  which  assume  this 
character,  it  only  manifests  itself  in  those  localities  and 
individuals  which  have  the  most  affinity  for  it.  Spring- 
ing from  an  alteration  in  the  constituent  elements  of  the 
atmosphere,  an  alteration  unknown  in  its  essence  but 
appreciable  in  its  effects,  it  is  propagated  through  the 
medium  of  that  fluid.  ...  A  great  number  of 
persons  were  struck  by  the  epidemic  a  few  days  after 
arriving  in  the  infected  places,  and  without  having 
communicated  with  any  patient." 

M.  Daviot  denies,  as  regards  an  epidemic  which  he 
describes,  that  it  generally  happened  that  all  or  the 
greater  number  of  the  members  of  a  family  were  attacked 
at  once,  and  states  that  it  was  quite  as  common  that  only 
a  certain  number  of  persons  living  under  one  roof  were 
affected,  while  the  successive  attacks  took  place  at 
considerable  intervals.  M.  Daviot  thinks  such  results 
can  only  be  accounted  for  by — 

"Similarity  of  organization  and  predisposition  in 
individuals  placed  under  the  same  hygienic  circum- 
stances, and,  therefore,  subject  to  the  same  morbific  influ- 
ences.    .     .     .     Will  any  one  contend   that  the  conta- 

'  Memoirs  on  Diplitheria  (New  Sydenham  Soc),  London,  1857. 


112  DIPHTHERIA. 

gious  principle  could  have  six  months,  a  year,  or  even 
more  of  incubation  before  its  development?  Such  an 
explanation  is  contrary  to  all  probability,  and  does  not 
require  to  be  refuted." 

M.  Daviot  did  not  meet  with  an  instance  where  diph- 
theria was  communicated  by  personal  intercourse.  He 
remarks  that  neither  the  attendants  nor  those  who  cauter- 
ized the  throats  of  affected  children  contracted  the  dis- 
ease. He  concludes  that  pharyngeal  diphtheria  is  not 
in  itself  contagious,  and  that  it  only  appears  to  be  so 
when  associated  with  eruptive  fever. 

Dr.  Crighton/  of  Edinburgh,  records  the  results  of  45 
cases  of  diphtheria  occurring  in  his  practice.  Of  these, 
25  were  males  and  20  females ;  out  of  this  number  9 
proved  fatal,  or  1  in  5.  Of  these,  6  died  of  asphyxia 
with  membranous  exudation  in  the  air-passages,  and  3 
by  pure  asthenia.  They  were  instances  of  faucial  diph- 
theria. In  one  case,  aged  21  months,  vulval  diphtheria 
occurred.  The  mean  age  of  the  fatal  cases  was  within  a 
fraction  of  seven  years. 

"  In  only  two  cases  was  there  anything  like  proof  of 
contagion,  and,  from  all  that  I  have  seen  of  diphtheria, 
I  believe  that,  although  it  would  be  incorrect  to  separate 
it  from  the  list  of  communicable  diseases,  yet  it  is  very 
feebly  so  compared  with  many  others.  I  may  mention 
one  instance  which  struck  me  particularly,  where,  in  a 
large  family  of  six  or  seven  children,  and  chiefly  under 
the  age  of  twelve,  a  child   had   the  disease  in  a  very 

'  Notes  on  an  Epidemic  of  Diphtheria.     By  R.  W.  Crighton. 


CONTAGION".  113 

severe  form,  and  although  he  was  never  isolated  during 
the  day  from  the  others,  but  lay  on  a  sofa  in  a  room 
where  I  generally  found  several  of  them  at  my  visit, 
they  all  escaped." 

Dr.  Moncton  {Med.  Times  and  Gaz.,  Feb.  26,  1857), 
after  much  experience  in  the  disease  during  epidemics 
which  prevailed  in  the  county  of  Kent,  says : — 

"No  decisive  instance  of  its  communicability  has  come 
before  me ;  on  the  contrary,  I  have  seen  it  attack  indi- 
viduals only,  in  a  family  of  liable  persons,  much  more 
frequently  than  I  think  scarlet  fever  would  have  done. 
My  own  conviction  is,  that  diphtheria  is  epidemic, 
endemic  (?'.  e.,  largely  affected  by  locality),  and  non-con- 
tagious, or,  if  contagious  at  all,  vastly  less  so  than 
scarlet  fever,  from  which  last  it  is  very  distinct." 

Dr.  Jenner,  in  his  lectures  upon  the  origin  of  diphthe- 
ria, draws  the  following  conclusions  : — 

"  First,  that  the  disease  is  infectious ;  second,  that  the  in- 
fected element  does  not  require  for  its  development  any 
of  the  ordinarily  considered  antihygienic  conditions; 
third,  that  the  family  constitution  is  one  of  the  most  im- 
portant elements  favoring  the  development  of  the  dis- 
ease and -determining  its  progress;  fourth^  that  it  is  very 
doubtful  even  if  any  of  these  hygienic  conditions  favor  its 
development  or  give  it  a  more  untoward  course  when  it 
occurs."' 

'  Diphtheria,  its  Symptoms  and  Treatment,  by  William  Jenner,  M.  D. 
London,  1861,  page  51. 

10- 


114  DIPHTHERIA. 

Space  would  fail  us,  if  we  attempted  to  bring  forward 
more  than  a  very  small  portion  of  the  argument  and  evi- 
dence wliich  have  been  offered  in  favor  of  the  contagious 
or  non-contagious  properties  of  diphtheria.  There 
are,  however,  one  or  two  points  which  we  may  consider 
further. 

In  connection  with  certian  epidemics,  especially  in 
France,  there  were  frequently  observed  cases  of  cuta- 
neous diphtheria,  which,  from  their  persistence  and 
superficial  site,  seemed  peculiarly  to  favor  transmission 
by  contagion.  As  a  general  rule,  this  was  never  devel- 
oped unless  when  the  epidermis  was  raised  or  removed; 
and  the  observations  of  M.  Trousseau,  and  others,  have 
incontestably  proved  that  the  diphtheritic  affections  of 
the  skin  are  of  a  nature  identical  with  those  which  have 
their  seat  in  the  mucous  membrane  of  the  larynx  and 
fauces. 

Now,  although  those  who  favor  the  idea  of  contagion 
find  in  the  phenomena  of  cutaneous  diphtheria  strong 
ground  for  the  support  of  the  theory  of  inoculation,  there 
are  facts  which  would  seem  equally  to  oppose  it.  For 
example,  it  has  been  observed  in  these  epidemics,  that 
the  false  membrane  upon  the  skin  not  only  presents 
itself  in  those  not  previously  affected  with  faucial  diph- 
theria, but  it  not  unfrequently  attacks  remote  parts,  such 
as  we  sljould  suppose  were  inaccessible  to  inoculation, 
as,  for  example,  the  folds  of  the  groins  in  children,  and 
the  spaces  between  the  toes.     ^'  A  jingle  well  observed 


CONTAGION.  115 

fact  of  this  kind  is  sufficient  to  cast  a  doubt  on  the  theory 
of  inoculation." 

Again,  it  sometimes  happens,  according  to  M.  Trous- 
seau, that  diphtheria,  especially  when  it  occurs  as  a 
sequel  to  measles  and  scarlatina,  is  complicated  with  an 
eruption  of  bullai  of  rupia  simplex.  These  often  become 
the  seat  of  cutaneous  exudation.  As  the  bulla  becomes 
flaccid  from  the  absorption  of  its  contents,  instead  of  the 
formation  of  a  thick  brownish  crust,  it  is  observed  that 
a  firm  concretion  can  be  felt  beneath  the  still  entire  epi- 
dermis. 

The  influence  which  meteorolosfical  and  cosmic  condi- 

o 

tions  exert  in  the  production  of  diphtheria,  is  no  better 
understood  than  is  the  relation  existing  between  these 
same  conditions  and  the  production  of  other  epidemic 
diseases. 

Bretonneau,  for  example,  had  the  idea  that  his  diph- 
theria needed  a  damp  atmosphere  for  its  development. 
In  the  recent  epidemics,  both  in  France  and  in  England, 
many  instances  are  recorded  where  the  disease  prevailed 
in  very  dry  and  high  situations.  And  in  our  own 
country,  similar  observations  have  been  made.  Dr. 
Wooster,  in  a  monograph  on  diphtheria  as  it  prevailed  in 
California,  explains  how  far  the  views  of  Bretonneau  are 
applicable  to  the  disease  as  it  presented  itself  to  his 
notice.     He  says  : — 

"  In  our  climate  the  air  in  summer  becomes  so  dry, 
that  if  an  ordinary  soft  wooden  pail  or  bucket,  be  half 
filled  with  water,  and  set  in  the  sun  in  the  open  air  for 


116  DIPHTHERIA. 

six  hours,  and  then  two  quarts  of  water  be  added,  it  will 
leak  through  the  joints  of  the  shrunken  staves,  above  the 
surface  of  the  first  portion  of  water.  A  miner  uses  a 
bucket  to  bail  water  from  a  hole  all  the  forenoon,  and, 
although  it  is  perfectly  saturated  with  water,  yet  if  he 
leaves  it  in  the  sun  while  he  goes  to  his  dinner,  when  he 
returns  it  will  often  fall  to  pieces  as  he  attempts  to  take 
it  up. 

"This  is  the  kind  of  air  in  which  the  disease  has 
occurred  with  unequalled  fatality  in  this  State.  In  this 
city  I  cannot  ascertain  that  a  case  has  occurred  in  that 
part  of  the  town  built  over,  or  near  the  waters  of  the  bay, 
or  on  the  salt  marshes  near  it.  But  I  have  seen  cases  in 
the  high  part  of  the  city,  and  on  bluff  headlands  extend- 
ing into  the  bay,  points  that,  from  their  elevation  and 
constant  exposure  to  a  strong  breeze,  would  be  thought 
inaccessible  by  any  morbid  effluvia." 

In  this  connection,  Ave  cannot  refrain  from  citing  the 
somewhat  poetical,  but  at  the  same  time  very  truthful 
remarks  of  Mr.  Ernest  Ilart.^ 

"  It  was  observed  of  diphtheria  in  France,  and  it  is 
equally  characteristic  of  its  course  in  England,  that  it  did 
not  obey  any  known  climatic  or  meteorological  laws. 
It  descended  upon  Tours,  in  the  rear  of  the  Legion  of  La 
Yendee ;  it  broke  out  in  crowded  and  ill- ventilated  bar- 
racks, and  it  spread  throughout  the  town.  It  visited 
alternately  the  open  hamlets  of  the  rural  departments 
and  the  crowded  courts  of  the  great  cities.     It  raged  in 

'  On  Diplitlieria,  its  Ilistoiy,  ^"^c,  by  Ernest  Hart,  London,  1S59. 


CONTAGION.  117 

Orleans  and  in  Paris,  througli  the  Sologne  and  in  the 
Loiret.  It  reached  the  sea-side,  and  fell  with  violence 
upon  the  infant  population  of  the  city  of  Boulogne.  It 
appeared  to  be  equally  independent  of  all  atmospheric 
conditions.  Was  a  theory  formed  that  its  intensity  de- 
pended upon  the  solar  influence,  and  that  the  heat  of  the 
summer  months  lent  fresh  force  to  its  destructive  attacks 
— soon  it  raged  with  greater  violence  in  the  winter 
months,  and  during  the  cold  season.  "Was  a  connection 
traced  between  the  localities  of  its  invasions,  and  the 
marshy  ill-drained  character  of  the  land — the  next  sea- 
son it  was  found  to  ravage  dry  and  elevated  stations  with 
equal  rage.  It  has  been  no  less  careless  of  the  limita- 
tions of  heat,  cold,  dryness,  and  moisture,  since  it  has 
established  a  camp  in  this  country.  -5^  ^  -^^  It  has  swept 
across  the  marshy  lowlands  of  Essex,  and  the  bleak 
moors  of  Yorkshire.  It  has  traversed  the  flowery  lanes 
of  Devon,  and  the  wild  flats  of  Cromwell  that  are  swept 
by  the  sea-breeze.  It  has  seated  itself  on  the  banks  of 
the  Thames,  scaled  the  romantic  heights  of  North  Wales, 
and  has  descended  into  the  Cornish  Mines.  Commencing 
in  the  spring  months,  it  has  continued  through  the 
summer,  and  if  extremes  of  temperature  have  appeared 
to  lend  it  fresh  vigor,  and  the  heat  of  the  dog-days,  or 
the  severe  frosts  and  sleet  of  winter  have  fostered  its 
strength,  yet  moderate  temperature  has  not  greatly  abated 
its  influence,  and  it  has  struck  a  blow  here  and  there 
through  all  the  seasons." 

Without  doubt,  diphtheria,  as  well  as  other  diseases  of 


113  DIPHTHERIA. 

a  similar   character,  follow  general   laws,    and  in   many 
cases  we  are  obli^'-ed  to  confess  our  entire  it<norance  as 

o  o 

to  the  exact  nature  of  those  laws. 

But  if  we  cannot  ascertain  the  influences  which  govern 
these  epidemics,  perhaps  on  closer  investigation  we  may 
discover  certain  individual  or  hygienic  circumstances 
which  may  affect  them  either  as^irect  or  as  predisposing 
causes.  Thus,  as  a  general  rule,  we  shall  find  that  diph- 
theria is  more  frequently  associated  with  the  ill-ventila- 
ted, contracted  hovels  of  the  poor,  seizing  by  preference 
upon  the  unhappy  subjects  depressed  by  poverty  and 
its  attendant  evils.  Yet  these  are  not  the  exclusive  con- 
ditions for  the  development  of  diphtheria.  We  find  in 
the  various  reports  of  these  later  epidemics  that  the  dis- 
ease has  made  its  appearance,  and  carried  off"  its  victims, 
in  the  abodes  of  refinement  and  wealth. 

"Zymotic  in  its  nature,  it  tends  to  fasten  upon 
whomsoever  is  debilitated  by  previous  disease,  or  by  a 
constitution  naturally  feeble  and  artificially  effeminized, 
or  whose  vitality  is  lowered  by  the  depressing  influences 
of  luxury,  indolence,  and  inactivity ;  and  the  habitual 
defiance  of  physical  and  hygienic  laws,  which  is  so  fre- 
quent an  element  in  fashionable  life.  Hence  individual 
causes  come  into  play,  and  introduce  this  associate  of  the 
poor  into  the  palaces  and  mansions  of  the  great,  which 
they  so  often  fringe.  Diphtheria  finds  there  its  victims 
pale  and  anaemic,  or  grossly  sanguineous,  and  unhealthily 
excited."' 

'  On  Dii-litli.jiia.     By  Ernest  H.-irt,  Lonrlon,  1S50. 


ALBUMINURIA.  119 

Finallj,  all  we  can  affirm  is^,  that,  as  a  general  rule, 
anti-hjgiemc  conditions  of  anj  kind  favor  the  invasion 
of  dipMheriaj  as  \Yell  as  of  other  similar  epidomio  dis* 
eases. 

One  element  in  the  nature  of  diphtheria  is  of  reeent 
discovery.  We  refer  to  the  presence  of  albuminous 
urine  in  the  dise^ise.  The  first  observation  upon  the 
relation  of  albuminuria  to  diphtheria  appears  to  have 
been  made  in  connection  with  a  case  reported  bj  Mr, 
Wade,  of  Birmingham,  to  the  Queen's  College  Medico- 
Chirurgical  Society  in  December,  1857,  and  afterwards 
published  in  his  Oh-sermii'ms  mi  DkjMhma}  Shortly 
after  this,  during  researches  on  this  disease  at  Paris, 
MM.  Bouchut  and  Empis  made  a  similar  discovery. 
Albuminuria  did  not  e:xist  in  every  case  examined,  but 
ii  was  present  in  twelve  out  of  fifteen  cases.  Both  of 
these  observers  attach  great  importance  to  this  renal 
complication,  as  affording  an  anatomical  explanation  of 
the  cause  of  death,  when  this  cannot  be  attributed  to 
either  of  the  other  modes,  viz.,  death  by  asphyxia  or 
general  poisoning.  In  fact,  it  was  considered  by  them 
to  indicate  the  infectious  nature  of  the  disease,  in  this 
respect  resembling  purulent  infection,  which  is  accom- 
panied by  a  similar  alteration  of  the  urine.  On  this 
point  M.  Bouchut  arrives  at  these  conclusions.  **  Albu- 
minuria in  the  absence  of  scai^latina  or  asphyxia  (de- 
pendent on  laryngeal  obstruction)  is  a  sign  in  diph- 
theritic diseases  of  a  eommen cement  of  purulent  infec- 


120  DIPHTHERIA. 

tion,  and  coincides  with  a  very  great  gravity  of  the 
disease."  These  conclusions  he  founds  on  the  observa- 
tions, that  both  in  diphtheria  and  purulent  infection 
there  are,  1st,  alteration  of  the  color  of  the  blood,  which 
assumes  a  bistre  tint;  2d,  masses  of  pulmonary  apo- 
plexy, more  or  less  numerous,  similar  to  those  which 
precede  the  development  of  metastatic  abscesses;  3d, 
ecchymoses  of  purpura  on  the  skin,  or  the  serous  mem- 
branes and  the  viscera.  MM.  Bouchut  and  Empis  are 
of  opinion  that  in  addition  to  the  preceding  alterations, 
there  is  nothing  farther  necessarj^  to  establish  the  connec- 
tion between  these  diseases  but  the  presence  of  visceral 
abscesses,  or  purident  collections  in  the  serous  mem- 
branes. 

In  all  the  children  under  their  care  for  diphtheria,  the 
urine  was  analyzed  both  by  heat  and  nitric  acid.  When 
albuminuria  was  present,  the  urine  contained  a  very 
large  proportion  of  salts,  which  rendered  it  cloud}^  and 
of  a  milky  appearance  at  the  moment  of  emission.  At 
first,  the  heat  caused  the  salts  to  be  held  in  solution, 
when  carried  to  a  higher  degree  of  heat,  the  albumen 
was  precipitated.  In  three  cases,  the  precipitate  was 
very  large,  in  the  remainder,  it  was  moderate  in  amount. 

Together  with  albumen,  Mr.  Wade  usually  found  in 
the  urine  tube  casts  and  renal  epithelium,  the  former 
being  either  ''small  waxy  casts,"  or  '^ epithelial  casts." 
He  is  of  opinion  that  albuminuria  produces  a  diminu- 
tion ill  the  total  amount  of  solid  excreta,  that  is,  that  the 
special  functions  of  the  kidney  are  suspended,  whereby 


ALBUMINURIA.  121 

symptoms  arise  which  are  indicative  "of  the  retention 
within  the  sj^steni  of  those  matters  which  should  be  ex- 
creted." 

Our  author  has  not  informed  us  at  what  period  of  the 
disease  he  has  first  detected  albuminuria^  neither  does 
he  give  any  observations  tending  to  show  how  far  the 
progress  of  the  disease  is  affected  by  the  condition  of 
the  kidneys,  which  would  seem  to  be  indicated  by  the 
presence  of  "casts,"  kc,  in  the  urine. 

More  recently,  Mr.  Wade,  in  speaking  of  this  subject, 
remarked  that  the  changes  are  more  commonly  micro- 
scopical, consisting  of  crowding  and  opacity  of  the  epi- 
thelium, which  is  most  readily  detached  and  rapidly 
disintegrates.  Casts  of  various  kinds  are  to  be  found  in 
some  specimens  of  the  albuminous  urine  of  diphtheria. 
Apart  from  its  early  occurrence,  there  seems  to  be  a 
special  tendency  to  albuminuria,  about  the  seventh  or 
eighth  day,  at  which  time  the  disorder  has  a  natural 
tendency  to  terminate.  Under  such  circumstances  it  is 
to  be  looked  upon  as  a  critical  phenomenon.  It  may 
occur  at  any  period. 

Diphtheritic  albuminuria  is  often  preceded  by  urine 
of  high  specific  gravity.  The  supervention  of  albu- 
minuria may  fail  to  reduce  this.  Mr.  Wade  therefore 
recommends  the  ingestion  of  bland  fluids  in  as  great 
quantity  as  the  patient  will  take— half  a  pint  every  hour 
or  two,  if  possible,  in  the  case  of  adults.^ 

In  a  paper,  communicated  to  the  British  and  'Foreign 

'  Lancet,  Aug.  23,  18G2. 
11 


122  DIPnTHERIA. 

Med.-Chirurrjical  Review,  Jan.  1860,  Mr.  Sanderson, 
upon  the  basis  of  eight  cases,  is  not  inclined  to  admit 
either  of  the  doctrines  advanced  by  Mr.  Wade.  He 
says : — 

"In  eight  cases  in  which  I  have  had  the  opportunity 
of  making  repeated  observations  as  to  the  condition  of 
the  urine,  the  only  ones  which  occurred  to  me  since  my 
attention  has  been  directed  to  the  subject,  it  has  been 
albuminous  in  all." 

Dr.  Sanderson,  having  given  a  brief  report  of  each  of 
these  cases,  goes  on  to  remark : — 

"Although  in  several  of  the  cases  above  related  the 
cessation  of  albuminuria  was  clearly  coincident  with  the 
amelioration  of  the  patient,  and  the  disappearance  of  the 
most  alarming  symptoms,  it  is  not  less  certain  that  in 
one  or  two  others  albumen  existed  in  large  quantities  in 
the  urine,  although  the  cases  maintained  a  mild  character 
throuo-hout.  From  this  it  mav  be  inferred  that  albu- 
minuria  is  not  in  itself  so  alarming  a  symptom  as  ^I. 
Bouchut  is  inclined  to  imagine." 

As  it  appeared  of  importance  to  Dr.  Sanderson  to 
ascertain  whether  the  existence  of  albuminuria  coincided 
with  the  solid  excreta  of  the  urine,  he  directed  his  ex- 
periments to  that  end.  lie  offers,  however,  only  one 
satisfactory  observation,  the  following : — 

Case  YI.  W.  D.,  male,  aged  30.  Albuminuria  first 
observed  about  the  eighth  day ;  disappeared  three  days 
after;  abundant. 

General    eltaraeter   of    symiUnns. — Extreuicly    grave ; 


ALBUMINUKIA.  123 

excessive  prostration;  intense  adynamia,  with  nervous 
agitation  and  busy  delirium.     Concretion  not  examined. 

Result — recovery, — Slow  convalescence,  with  extreme 
muscular  weakness. 

During  a  period  of  about  nine  days  the  albuminuria 
continued.  During  this  time  observations  were  made  as 
to  this  condition  of  the  urine.  "Without  giving  the  two 
tables  of  analysis,  we  come  directly  to  the  result. 

"At  the  acme  of  the  disease,  when  the  urine  was 
intensely  albuminous,  when  there  was  complete  ano- 
rexia, and  the  ingesta  were  reduced  to  a  minimum,  the 
quantity  of  urea  excreted  in  a  period  of  twenty-four 
hours  was  about  twice  as  great  as  that  excreted  during  a 
similar  period  when  convalescence  was  established,  and 
he  was  eating  with  an  appetite  the  ordinary  diet  of  the 
hospital,  with  extras. 

"The  above,  facts  show  that  diphtheria  agrees  with 
the  other  pyrexia  in  being  attended  with  a  marked  in- 
crease in  the  excretion  of  nrea,  and  that  the  existence  in 
the  kidney  of  the  condition  which  is  implied  by  albumen 
and  fibrinous  casts  in  the  urine,  does  not  necessarily 
interfere  with  that  increase  in  the  elimination  of  nitro- 
genous material.  There  is,  therefore,  no  reason  to  ap- 
prehend the  occurrence  of  urasmia  as  a  consequence  of 
the  renal  complication  in  diphtheria ;  this  complication 
not  being  the  cause  of  the  dyscrasia,  but  merely  the 
index  of  its  existence." 

With  reference  to  the  presence  of  albuminuria  in 
diphtheria,  there  have  been  but  few  accurate  observa- 


12i  DIPHTHERIA. 

tious  made,  and,  in  fact,  until  comparatively  recently,  it 
Avas  tliongbt  that  one  distinctive  mark  of  diphtheria, 
over  other  kindred  diseases,  was,  that  there  were  no 
albumen  and  no  dropsy  present.  Certain  it  is  that  albu- 
minuria has  manifested  itself  throughout  almost  the 
entire  course  of  grave  cases  of  diphtheria,  and  which, 
have  3^et  terminated  favorably.  On  the  other  hand, 
cases  have  occurred  which  have  proved  fatal  when  it 
has  been  absent. 

There  can  be  no  doubt  of  the  serious  character  of  this 
renal  complication,  but  further  research  and  observation 
are  necessary  before  we  can  ascribe  to  it  any  settled 
prognostic  value. 

In  this  connection  we  may  also  speak  of  the  remark- 
able after  symptoms  of  diphtheria,  whicli  have  been 
observed  by  almost  every  practitioner  who  has  had  even 
a  limited  experience  during  the  epidemics  of  the  last  few 
years,  and  which  have  been  particularly  referred  to  by 
MM.  Trousseau  and  Bretonneau,  and  also  by  M.  Faure. 

After  apparent  recovery  from  the  immediate  effects  of 
the  disease,  in  many  cases  there  still  seems  to  be  lurking 
in  the  system  a  morbid  poison,  whose  special  affinity  is 
for  the  nervous  system.  Thus,  prominent  among  the 
sequelae  of  diphtheria,  is  paralysis  in  its  various  forms, 
more  frequently  local  than  general,  also  otalgia,  amau- 
rosis, headache,  ophthalmia,  &g.  Epidemics  of  this  last 
have  been  observed  in  Germany,  and  were  described  by 
Graefe  in  1854:,^  and,  in  France,  by  ^[.  Jobert  in  1857."^ 

'  Gazette  Ilebilomaflaire,  185G.  ^  Archives  Geuerales,  1S57. 


SEQUELS.  125 

The  most  frequent  form  of  paralysis  lias  been  that  of 
the  soft  palate.  The  symptoms  are  a  nasal  twang  in  the 
speech^  incapacity  for  suction,  and  the  regurgitation  of 
fluids  by  the  nostrils.  This  form  was  thought  both  by 
M.  Trousseau  and  others  to  be  local  in  its  origin.  But 
further  observation  has  led  them  to  change  their  views. 
M.  Trousseau  makes  the  following  clinical  remarks : — ■ 
"  The  pathology  of  the  paralytic  afl'ection  was,  for  a 
long  time,  altogether  misunderstood  both  by  himself  and 
others.  In  consequence  of  its  being  more  frequently 
local  than  general,  in  other  words,  the  palate  and 
pharynx  being  more  "usually  affected  with  paralysis 
than  the  system  generally,  he  was  for  a  long  time  under 
the  impression  that  the  loss  of  power  was  dependent 
upon  the  inflammation  of  the  coats  of  the  nerves  supply- 
ing these  parts,  and  on  infiltration  producing  pressure  on 
their  motor  muscles.  A  more  extensive  experience, 
however,  of  the  general  character  of  the  paralysis  which 
accompanies  and  follows  diphtheritic  affections,  caused 
him  to  change  his  views,  and  he  now  believes  that  loss  of 
power  and  sensibility  is  the  direct  consequence  of  the 
peculiar  diphtheritic  poison  acting  generally  on  the  sys- 
tem, and  strangely  modifying  the  blood.  He  further 
stated  a  fact  which  has  often  come  under  his  observation, 
that  many  children  who  have  been  subjected  to  the 
operation  of  tracheotomy  fall  victims  to  paralysis  of  the 
epiglottis  and  larynx."^ 

'  Med.  Times  and  Gazette,  Jan.  27,  1859. 
11- 


126  DIPHTHERIA. 

Again,  in  a  communication  to  the  Gazelle  des 
II6]jilaux,  I860,  M.  Trousseau  remarks  that  this  affec- 
tion may  be  analogous  to  what  is  observed  in  certain 
cachexias.  One  curious  circumstance  in  diphtheritic 
paralysis  is  the  temporary  extinction  of  venereal  desire, 
Avhich  occurs  at  a  very  early  period,  even  in  those 
possessed  of  considerable  genital  ardor. 

In  a  paper  read  before  the  Royal  Med.  and  Chir. 
Society,  March  24,  1863,  Dr.  Greenhow  remarked  that 
he  had  observed  nervous  affections  were  more  frequent 
after  the  worst  cases  of  diphtheria,  and  to  bear  some  pro- 
portion even  to  the  local  severity  of  the  attack  ;  he  had 
noticed  that  the  paral^^sis  and  anassthesia  w^ere  sometimes 
more  complete  on  that  side  of  the  fauces  which  had  been 
most  severely  affected  by  the  primary  disease ;  he  had 
found  that  a  brief  period  of  convalescence  had  almost 
always  intervened  between  the  disappearance  of  the  sore 
throat  and  the  accession  of  the  nerve  symptoms.  This 
seemed  important,  as  it  went  far  to  show  that  paralysis 
could  not  be  entirely  attributable  either  to  the  albuminu- 
ria, which  often  accompanied  the  acute  stage,  or  to  the 
anaemia,  Avhich  closely  follows  it,  as  patients  had  often 
got  rid  of  the  former  symptoms,  and  had  begun  to  get 
strength  and  flesh  before  the  accession  of  paralytic  symp- 
toms. These  nerve  affections  are  progressive  in  the 
same  set  of  muscles,  but  do  not  attain  their  maximum  of 
intensity  even  in  the  same  set  of  muscles.  The  muscles 
of  the  fauces  are  the  earliest  and  the  most  frequently 
attacked,  and  sometimes  the  only  ones;  next,  impairment 


SEQUELS.  127 

of  vision,  probably  due  to  paralysis  of  the  ciliary  mus- 
cles, appeared  to  be  the  most  frequent  of  tbe  nervous 
disorders  consequent  on  diphtheria :  a  great  majority  of 
sufferers  from  these  nerve  affections  recover.  As  to 
treatment,  Dr.  Greenhow  advised  generous  diet,  rest  in 
bed,  &c.  He  considered  nux  vomica  and  strychnine  as 
very  valuable  remedies  after  the  complete  development 
of  the  paralytic  symptoms. 

In  the  Med,  Times  and  Gazette,  January  4th,  1860,  M. 
Rover  makes  the  followinsr  statement : — 

During  the  year  1860,  there  were  200  cases  of  diph- 
theria at  the  Hopital  des  Enfans,  in  Paris;  paralytic  symp- 
toms followed  in  thirty-one  of  these  cases.  The  propor- 
tion was  really  greater,  several  children  having  been  re- 
moved from  the  hospital  prior  to  the  period  at  which 
consecutive  symptoms  are  usually  developed.  M.  Royer 
believes  that  these  cases  of  secondary  paralysis  are  as 
rare  in  the  other  acute  diseases  of  children,  as  they  are 
common  in  diphtheria.  Of  forty  cases  of  diphtheritic 
paralysis,  which  have  come  under  his  notice,  the  most 
frequent  age  was  from  four  to  six  years,  there  being  21 
female  to  17  male  infants.  In  almost  all  cases,  the  para- 
lysis has  commenced  by  the  pharynx  and  velum  palati, 
as  shown  by  the  nasal  twang  and  dysphagia.  Its  occur- 
rence would  seem  to  be  a  proof  of  a  greater  amount  of 
blood  poisoning.  The  usual  appearance  is  from  the 
fourth  to  the  eighth  day;  its  mean  duration  is  about  a 
month.    As  a  general  rule,  the  prognosis  is  not  unfavora- 


128  DIPHTHERIA. 

ble.  Tonics,  iron,  sulphurous  preparations,  and  tlie 
application  of  electricity  constitute  tlie  chief  treatment. 

A  paper  was  read  before  the  Prussian  Association  for 
Scientific  Medicine,  in  May,  1861,  by  Dr.  Ebert,  upon  the 
subject  of  diphtheritic  paralysis,  which  gave  rise  to  an 
interesting  discussion.  Dr.  Ebert  referred  to  cases 
recently  published  by  Bouillon  La  Grange,  in  which  not 
only  the  soft  palate,  but  also  vision,  smell,  taste,  and 
touch,  the  throat,  oesophagus  and  the  limbs  had  been 
paralyzed ;  and  then  related  a  case  which  had  fallen 
under  his  own  observation.  Dr.  E.  believed  that  such 
palsies  originated  in  the  same  way  as  rheumatic  paralysis, 
and  that  a  cold  would  be  sufficient  to  produce  paralysis 
in  a  patient  who  had  suffered  from  diphtheria.  Prof.  A. 
Yon  Graefe  denied  that  there  Avas  any  connection  between 
common  paralysis  and  the  diphtheritic  disease;  cases  of 
paralysis  occurred  after  every  grave  disease  of  the  nerv- 
ous system,  as  typhoid  fever,  erysipelas,  &c.  It  was  not 
difficult  to  trace  the  origin  of  the  paralj^sis  in  diphtheria, 
as  the  nervous  system  was  greatly  affected.  Every  dis- 
ease which  was  accompanied  by  fever,  was  also  accompa- 
nied by  paralysis  of  accommodation,  and  a  semi-paralytic 
state  of  most  of  the  muscles  of  the  eye.  If  the  large  num- 
ber of  epidemics  which  had  been  observed  in  France  was 
considered,  the  number  of  cases  of  paralysis  was  very 
small  when  compared  with  the  frequent  occurrence  of 
palsy  after  other  grave  diseases.^ 

M.   Maingault  finds   that   the  impairment   of    vision 

>  Med.  Times  aud  Gazette,  Maj,  ISGl. 


SEQUELAE.  129 

comes  next  in  order  of  frequency  after  tlie  affection  of 
the  soft  palate.  It  varies  in  duration  from  a  few  days  to 
six  months,  and  in  degree  from  the  mere  inability  to  read 
small  print  to  perfect  blindness.  The  ophthalmoscope 
3'ields  no  information;  its  sudden  accession  and  rapid 
disappearance  lead  us  to  regard  it  as  purely  neurotic.^ 

Dr.  Wade  remarks  {Lancet,  Aug.  23,  1862)  that  paraly- 
sis, may  follow  as  a  kidney  complication,  and  may  attend 
slight,  as  well  as  severe  cases  of  diphtheria. 

In  one  case  under  his  observation  the  paralysis 
has  lasted  two  years,  and  may  be  considered  as  perma- 
nent. 

Dr.  Jenner,  in  his  work  on  diphtheria,  observes  that  the 
heart  is  the  organ  next  in  order  of  frequency  to  manifest 
disordered  innervation  ;  the  patient  dies  from  a  literal 
asphyxia.  In  some  cases,  the  paralysis  is  more  widely 
extended  :  in  these  recovery  is  rare,  death  ensuing  as  from 
general  paralysis. 

But  it  is  to  Dr.  Faure  that  we  are  more  particularly 
indebted  for  the  most  complete  account  of  these  remote 
consequences  of  diphtheria.  He  describes  this  peculiar 
condition  of  the  system 

"As  a  state  characterized  by  a  gradually  increasing 
loss  of  power,  showing  itself  especially  in  all  those  func- 
tions connected  with  muscular  movement.  In  some 
instances,  several  sets  of  organs  are  affected,  in  others 
only  one,  while  again  in  others,  the  whole  system  is 
involved  in  the  general  debility.     But  whatever  are  the 

1  Brit,  and  For.  Med.-Cliir.  Review,  18G2. 


130  DIPHTnERIA. 

variations  in  this  respect,  there  is  no  definite  relation 
between  the  severity  of  the  primary  symptoms  of  diph- 
theria and  that  of  the  sequela3.  The  primary  symptoms, 
though  very  formidable,  do  yet  by  no  means  of  necessity 
prove  fatal ;  while,  on  the  other  hand,  the  comparative 
mildness  of  the  attack  will  not  justify  an  absolutely 
favorable  prognosis,  since  death  sometimes  follows  where 
everything  had  seemed  to  warrant  the  most  confident 
expectation  of  recovery." 

Several  cases  are  given  by  M.  Faure,  in  illustration  of 
the  various  phases  of  this  condition,  and  he  sums  up  as 
follows : — 

"Some  time  after  an  attack  of  diphtheria,  from  which 
the  patient  has  so  completely  recovered  that  no  trace  of 
false  membrane  is  left  behind,  the  skin  grows  more  and 
more  colorless  without  apparent  cause,  so  that  at  length 
it  assumes  almost  a  livid  pallor.  Severe  pains  begin  at 
the  same  time  to  be  felt  in  the  joints,  the  patient  loses 
power  over  his  limbs,  and  soon  sinks  into  a  state  of 
indescribable  weakness.  At  the  same  time,  the  disorders 
that  appear  in  different  functions  show  that  the  various 
organs  which  should  minister  to  them  are  involved  so 
far  as  they  are  dependent  upon  muscular  power.  In  this 
respect,  however,  the  phenomena  are  not  constant,  for 
sometimes  it  is  one  set  of  organs,  and  sometimes  another 
which  suffers  most  from  this  weakness.  Yery  generally, 
in  consequence  of  the  want  of  muscular  power,  the 
patient  becomes  unable  to  sit  upright,  or  does  so  with 
great  difiiculty,  while  the  legs  cannot  bear  the  weight  of 


SEQUELS.  131 

the  body ;  all  the  movements  grow  uncertain,  tottering, 
hesitating  and  apparently  purposeless.  Yery  remarka- 
ble disorders  show  themselves  also  within  the  throat,  for 
the  velum  is  completely  paralyzed,  and  hangs  down  like 
a  flaccid  lifeless  curtain,  which  interferes  with  speech  and 
deglutition.  All  the  muscles  of  the  jaw,  neck,  and  chest 
are  partially  paralyzed  in  consequence  of  which  masti- 
cation is  rendered  difficult,  and  the  food  can  be  neither 
easily  moved  about  in  the  mouth  nor  readily  swallowed. 
Vision  is  impaired,  squinting  is  not  unusual.  The  sensi- 
bility of  the  skin  is  much  diminished,  in  the  limbs  it  is 
sometimes  completely  lost,  though  morbid  sensations, 
such,  for  instance,  as  formication,  are  sometimes  experi- 
enced. CEdema  of  the  various  parts  often  occurs,  and 
occasionally  parts,  here  and  there,  lose  their  vitality,  and 
become  gangrenous.  No  general  reaction  occurs  ;  fever 
is  rare.  The  features  grow  duller  and  more  and  more 
expressionless,  though  a  foolish  smile  sometimes  crosses 
them,  or  now  and  then  a  ray  of  intelligence  appears. 
Some  patients  have  frequent  fainting  fits.  As  the  condi- 
tion goes  on  from  bad  to  worse,  the  weakness  becomes 
extreme,  and  death  at  length  follows  some  fainting  fit,  or 
takes  place  when  exhaustion  has  reached  its  uttermost ; 
life,  as  it  were,  quietly,  almost  imperceptibly,  passing 
away." 

Such  are  some  of  the  most  common  sequels  of  diph- 
theria. It  is  not  to  be  understood,  that  in  these  cases  a 
fatal  termination  is  necessary,  nor  that  the  symptoms  are 


132  DIPHTHERIA. 

necessarily  so   severe   as   have   been   depicted   by    Dr. 
Fail  re. 

Further  observations  will  undoubtedly  clear  away 
much  that  is  obscure  upon  these  singular  after-efFects  of 
the  disease.  Even  in  our  present  state  of  knowledge  of 
them,  they  certainly  furnish  materials  towards  the  solu- 
tion of  the  question — the  identity  or  non-identity  of  diph- 
theria and  scarlatina. 

These  cases  are  to  be  treated  on  tonic  principles.  The 
nervine  tonics  are  especially  indicated.  In  cases  of  local 
paralysis,  astringents,  feeble  cauterization,  and  electricity 
may  be  employed. 

Eecent  observations  have  shown,  that  clots  in  the  heart 
may  undoubtedly  occasion  the  sudden  deaths  which  are 
sometimes  witnessed  in  diphtheria.  Dr.  Thompson  calls 
the  attention  of  the  profession  to  this  fact,  in  a  communi- 
cation to  the  London  Med.  Times  and  Gazette,  Jan.  1860, 
and  in  the  American  Journal  of  the  Med.  Sciences  for 
April,  1864,  Dr.  J.  F.  Meigs,  of  Philadelphia,  reports 
three  cases  of  death  from  this  cause. 

Our  knowledge  of  the  nature  of  diphtheria  may  be 
summed  up  in  the  following  words : — 

Diphtheria  is  a  specific  disease.  This  fact  is  shown  by 
its  origin,  its  progress,  its  manner  of  termination,  and  its 
sequelae. 

Its  diagnostic  sign  is  the  formation  of  an  aplastic  mem- 
branous exudation  upon  any  portion  of  the  cutaneous  or 
mucous  surface  which  is  exposed  to  the  contact  of  the 
atniospbcre. 


TREATMENT.  133 

It  is  propagated  by  infection  and  contagion,  and  is 
both  epidemic  and  sporadic  in  its  invasion. 

Its  characters  plainly  indicate  that  it  belongs  to  the 
category  of  hlood  diseases. 

It  is  not  allied  either  to  cynanche  trachealis,  or  to 
scarlatina. 

The  treatment  is  to  be  directed  to  the  control  of  the 
exudation,  and  to  the  support  of  the  constitution  by 
means  of  tonics,  stimulants,  and  by  a  nutritious  diet.  Of 
this  we  shall  speak  next. 

Treatvient. — Like  all  diseases  which  have  prevailed 
epidemically,  and  which  have  appalled  by  their  severity 
and  fatality,  or  perplexed  by  their  novelty,  diphtheria 
has  been  subjected  to  a  great  variety  of  treatment.  It  is 
only  within  the  last  few  years  that  anything  like  iman- 
imity  has  existed  in  the  profession  in  regard  to  this 
important  point.  ISTot  to  go  back  further  than  the  period 
of  Bretonneau's  memoir  on  this  subject,  we  shall  find 
that  an  activity  of  treatment  prevailed  which  would 
scarcely  coincide  with  the  ideas  of  the  present  day. 
Bleeding,  both  local  and  general,  blisters,  certain  local 
applications  to  the  pharynx,  rapid  mercurialization, 
formed  the  treatment  in  all  cases.  Mercury,  in  fact, 
was  considered  as  the  sheet  anchor  by  a  great  majority 
of  medical  men.  To  quote  the  words  of  Dr.  Bard  :  "  But 
although  I  consider  mercury  as  the  basis  of  the  cure, 
especially  in  the  beginning  of  this  disease,  I  do  not  by 
an}^  means  intend  to  condemn  or  omit  the  use  of  proper 
alexlpharmics  and  antiseptics."  Although  a  few  practi- 
12 


134  DIPHTHERIA. 

tioners  may  still  make  use  of  this  therapeutic  agent,  it  is 
now  generally  agreed  that  such  is  the  asthenic  nature  of 
the  disease  at  the  present  day,  that  depletion  is  not  borne 
well  in  any  form,  neither  is  the  action  of  mercury  defen- 
sible either  in  theory  or  practice. 

As  we  are  still  unacquainted  with  any  specific  capable 
of  arresting  the  course  of  diphtheria,  our  treatment  must 
be  directed  simply  to  the  conducting  our  patient  in  his 
progress  through  the  disease.  In  the  first  place  strict 
attention  to  certain  hygienic  rules  is  necessary.  The 
most  scrupulous  cleanliness  of  person  and  surroundings, 
free  and  uninterrupted  ventilation  should  be  insisted  on. 
If  there  are  children  in  the  family  where  the  disease 
breaks  out,  the  well  ones  should  be  sent  away,  or  at 
least  should  be  kept  out  of  the  room  where  the  infected 
individual  lies. 

Mr.  Wade  recommends  that  the  patient  in  all  cases 
should  be  clothed  in  a  flannel  gown  and  kept  in  bed.  I 
believe  that  the  adoption  of  this  plan  would  have  saved 
almost  innumerable  lives.' 

In  the  very  early  stages  of  the  disease,  if  there  is  much 
heat  and  engorgement  about  the  throat,  cold  wet  com- 
presses may  for  a  time  give  relief.  As  the  disease  pro- 
gresses, warm  fomentations,  and  emollient  applications 
generally,  may  be  substituted.  Blisters  are  to  be  avoid- 
ed, both  on  account  of  their  adding,  by  their  irritation, 
to  the  eno:orQ:ement  and  to  the  cellular  infiltration,  and 

DO  ' 

»  Lancet,  Aug.  23, 1852. 


TREATMENT.  135 

on  account  of  their  liability  to  take  on  a  diplitlieritic  or 
sloughy  appearance.  As  everything  in  the  aspect  of  the 
disease,  from  the  first,  indicates  that  the  powers  of  life 
must  not  be  lowered,  but  on  the  contrary  that  the  tend- 
ency to  prostration  must  be  averted  in  every  way,  neither 
leeches  nor  local  bleeding  are  admissible,  except  perhaps 
in  very  rare  exceptional  cases.  In  certain  epidemics, 
there  is  also  danger  that  the  punctures  might  take  on  a 
sloughy  character. 

Many  practitioners  commence  the  treatment  of  diph- 
theria with  the  administration  of  an  emetic  or  a  purga- 
tive. Under  certain  circumstances  an  emetic  may  be 
advisable,  particularly  when  there  is  an  early  tendency 
to  croupal  symptoms.  For  the  purpose,  fall  doses  of 
ipecac  are  preferable.  Anything  like  purging,  however, 
is  to  be  sedulously  avoided  on  account  of  the  asthenic 
nature  of  the  disease.  The  bowels  may  be  moved  by 
simple  enemata,  or  by  some  mild  laxative. 

There  are  occasional  cases  of  diphtheria  so  mild  in 
character  that  local  applications  to  the  fauces  may  be 
sufScient,  but  as  a  general  rule  it  is  conceded  that  the 
disease  requires  a  tonic  and  sustaining  treatment,  par- 
ticularly is  this  the  case  at  a  late  period  of  the  disorder. 
In  cases  at  all  severe,  the  tendency  is  to  depression  and 
to  death  by  asthenia,  unless  earlier  terminated  by 
asphyxia. 

Stimulants  and  nourishment  should  be  commenced 
with  early,  and  persisted  in  systematically.  The  amount, 
of  course,  must  depend  upon  circumstances,  but  in  order 


136  DIPHTHERIA. 

to  insure  efficiency;  they  should  be  varied,  and  given  in 
small  doses  at  regular  and  frequent  intervals  ;  if  rejected 
by  the  stomach,  they  should  be  given  in  the  form  of 
enemata.  So  also  with  respect  to  children,  when  they 
are  frightened  and  distressed  by  painful  attempts  at 
swallowing,  and  absolutely  refuse  everything,  we  have 
the  same  resource. 

Injections  of  beef-tea,  with  braedy  and  quinine,  may 
be  employed,  and  thus  life  be  not  unfrequently  sustained, 
when  otherwise  it  would  inevitably  have  been  ex- 
tinguished. 

With  regard  to  the  particular  form  of  internal  tonics, 
there  is  a  variety  of  opinion.  There  are  some  which, 
perhaps,  promise  a  greater  chance  of  success  than  others, 
among  which  we  may  mention  quinine,  tinct.  ferri 
chloridi,  and  chlorate  of  potash.  But  as  each  of  these 
has  powerful  advocates  in  its  favor,  we  imagine  that, 
provided  the  strength  of  the  patient  be  sustained,  it  is  of 
little  importance  by  which  of  these  tonics  it  is  accom- 
plished. 

The  tincture  of  chloride  of  iron  seems  now  to  be  pre- 
ferred by  the  great  majority  of  practitioners,  on  account 
of  its  unquestionable  usefulness  in  the  more  asthenic 
forms  of  disease.  The  dose  is  from  10  to  15  drops,  in 
water,  every  three  or  four  hours. 

"  Of  the  many  internal  remedies  which  have  been  ad- 
vised, we  do  not  know  of  any  on  which  so  much  reliance 
can  be  placed  as  on  the  tincture  of  sesquichloride  of  iron, 
with  chlorate  of  potass,  chloric  ether  and  hydrochloric 


TREATMENT.  137 

acid  in  the  form  of  mixture,  sweetened  with  syrup,  full 
doses  being  employed  according  to  the  age  of  the  patient, 
and  frequently  repeated.  A  free  use  should  be  made  of 
generous  wine,  beef-tea,  coffee,  eggs,  in  combination  with 
brandy  and  wine,  milk,  and  whatever  other  form  of  nu- 
triment the  ingenuity  of  the  surgeon  or  the  fancy  of  the 
patient  can  suggest."^ 

Quinine  may  be  administered  in  mixture,  with  or 
without  the  dilute  hydrochloric  acid,  or  in  the  form  of 
pill;  the  dose  and  frequency  of  repetition  must  be 
governed  by  circumstances.  If  the  chlorate  of  potash 
be  preferred,  it  should  be  given  in  doses  of  from  four  to 
eight  grains,  according  to  age,  in  a  bitter  infusion  with 
two  to  five  drops  of  the  dilute  hydrochloric  acid. 

We  come  now  to  speak  of  the  auxiliary  measures  to 
be  adopted  in  the  treatment  of  this  disease,  and  first,  of 
the  local  applications  to  the  fauces.  The  propriety  of 
these  has  been  called  in  question  by  some  writers,  on 
the  ground  that  the  disease  is  a  constitutional  one,  and, 
therefore,  that  they  can  be  of  no  service.  But  there  can 
be  no  more  reason  why  the  local  remedies  are  not  as 
applicable  to  this  affection  as  in  other  constitutional  dis- 
eases, for  example,  as  in  syphilis,  scrofula,  carbuncle, 
&c.  In  an  excellent  paper  by  Dr.  Bristowe,^  on  the 
treatment  of  diphtheria,  the  following  reasons  are  given 
for  discarding  heroic  applications  to  the  fauces : — 

•  Lancet,  Sauitarj  Commission. 

2  Med.  Times  and  Gazette,  Sept.  1859. 

12* 


138  DIPHTHERIA. 

"  1.  That  the  throat  affection  is  merely  a  local  evidence 
of  a  constitutional  disease,  which  is  "unlikely  to  be  ar- 
rested in  its  progress  by  any  treatment  directed  to  the 
secondary  manifestations  only.  2.  That  the  throat  affec- 
tion rarely  kills,  except  by  involving  organs,  such  as  the 
trachea  and  deeper  tissues  of  the  neck,  which  are  beyond 
the  region  of  the  possible  influence  of  such  agents.  3. 
That  if  the  theoretical  correctness  even  of  such  treatment 
be  admitted,  the  application  of  remedies  to  the  surface 
of  a  thick  false  membrane,  with  the  hope  that  they  may 
affect  the  subjacent  mucous  tissue,  is  not  only  clumsy, 
but,  as  regards  the  object  intended,  practically  useless; 
and  that  the  prior  forcible  removal  of  the  membrane 
from  the  entire  surface,  in  order  to  their  efficient  em- 
ployment, is  unjustifiable  in  the  early  stage,  even  if 
possible,  and  is  likely  only  to  be  followed  by  increased 
inflammation,  and  reproduction  of  false  membrane.  .  .  . 
Of  course,  if  a  gangrenous  state  of  the  tonsils,  or  any 
other  local  complication,  supervenes,  such  topical  appli- 
cations as  are  commonly  had  recourse  to  in  like  condi- 
tions of  the  throat  should  be  employed." 

While  we  concur  in  the  remarks  of  Dr.  Bristowe  so 
far  as  regards  the  forcible  removal  of  the  false  mem- 
brane, particularly  in  the  early  stages,  the  experienae  of 
almost  all  medical  men  of  the  present  day  bears  witness 
to  the  eflicacy  of  the  application  of  caustics  or  escharotics 
to  the  throat. 

M.  Trousseau  remarks  that  topical  medication  is,  //«?• 


TREATMENT.  139 

excellence,  the  treatment,  notwithstanding  the  opposition 
to  it.' 

Mr.  Wade  maintains  that  interference  with  the  false 
membrane  will  not  prevent  its  reprodaction,  nor  will  it 
prevent  laryngeal  complication.  We  are  justified  in 
interfering  with  the  throat  exudation  when  there  is 
excessive  fetor,  or  when  it  is  so  copious  as  to  interfere 
with  respirations  or  deglutition,  not  otherwise.^ 

"Local  treatment,"  says  Dr.  Greenhow,  "applied  to 
the  throat  internally,  has  been  almost  universally 
adopted  in  the  treatment  of  diphtheria ;  and  though  I 
by  no  means  deny  its  value  when  judiciously  employed, 
I  am  sure  much  mischief  has  been  produced  by  its  indis- 
criminate use,  especially  by  the  tearing  away  of  the  exu- 
dation by  probing  or  similar  contrivances  for  the  applica- 
tion of  nitrate  of  silver  or  of  strong  caustic  solutions. 
Observing  that  removal  of  the  exudation,  and  the  applica- 
tion of  remedies  to  the  adjacent  surface,  neither  shortened 
the  duration  nor  sensibly  modified  the  progress  of  the 
complaint,  but  that  the  false  membrane  rarely  failed  to 
be  renewed  in  a  few  hours,  I  very  soon  discontinued 
this  rough  local  medication  to  the  tender  and  already 
enfeebled  mucous  membrane.  The  propriety  of  this 
course  became  evident  at  the  very  first  post-mortem 
examination  I  had  the  opportunity  of  witnessing,  and 
has  been  confirmed  by  all  my  subsequent  experience.  In 
the  fi/rst  place,  the  application  can  but  rarely  extend  to 
the  entire  diseased  surface,  and,  in  the  next,  the  subjacent 

»  Brit.  Med.  Journal.  2  Lancet,  Aug.  23,  18G2. 


14:0  DIPHTHERIA. 

tissues  are  so  deeply  involved  in  cases  of  really  malig- 
nant diphtheria,  that  any  application  to  the  surface  of 
the   mucous   membrane   could   apparently  exercise   no 

beneficial  influence  upon  the  disease The 

only  instance  in  which  much  benefit  can  be  expected 
to  arise  from  the  local  application  of  escharotics,  is 
when  the  patient  is  seen  at  a  very  early  stage  of  the 
illness  while  the  throat  is  simply  inflamed  or  the  exuda- 
tion, if  it  be  already  present,  is  circumscribed  fully  in 
view  and  surrounded  by  healthy  tissue."* 

On  the  other  hand,  some  writers  maintain  that  the 
disease  at  the  outset  is  a  local  one,  which  rapidly  brings 
on  a  general  intoxication.  This  would  be  a  still  stronger 
argument — if  we  granted  this  to  be  true — for  these  very 
local  remedies,  if  applied  in  season,  might  prevent  a 
further  extension  of  the  disease. 

There  are  a  multitude  of  substances  which  have  been 
employed  as  local  applications  to  the  fauces,  each  of 
which  has  its  special  advocates.  During  the  last  four 
years  the  nitrate  of  silver,  either  solid  or  in  solution,  has 
been  perhaps  more  extensively  used  than  any  other  sub- 
stance. This,  when  used  early  in  the  disease,  seems  in 
many  cases  to  check  the  progress  of  the  exudation ;  yet 
it  does  not  answer  the  purpose  altogether,  and  further 
experience  has  somewhat  diminished  confidence  in  it. 
Indeed,  in  some  instances  it  is  a  question  whether  the 
free  application  of  this  caustic  does  not  rather  add  to  the 
evil. 

'  On  Diphtheria,  by  Dr.  E.  Headlam  Greenliow. 


TREATMENT.  1-il 

"I  have  mentioned  that  I  tliought  that  tlie  indiscrimi- 
nate mopping  of  the  fauces,  as  it  is  called,  with  solutions 
of  nitrate  of  silver,  was  frequently  attended  with  in- 
jurious results  in  this  disease,  principally,  I  believe,  for 
this  reason,  that,  owing  to  the  struggles  of  the  little 
patient,  it  is  impossible  to  apply  the  caustic  solution 
with  that  precision  which  the  case  absolutely  requires. 
Thus,  it  is  applied  to  parts  which  are  entirely  free  from 
disease.  I  have  been  told  of  cases  where  the  inside  of 
the  cheeks  has  been  covered  with  it;  in  coughing,  a  por- 
tion of  it  has  been  expelled  upwards  through  the  nose, 
corroding  the  susceptible  surface  of  its  mucous  mem- 
brane ;  and,  again,  other  portions  of  it  have  seemed  to 
pass  downwards  into  the  pharynx  and  oesophagus ;  and 
I  am  not  sure  that,  during  the  convulsive  struggling  of 
the  patient  in  resistance,  some  of  it  may  not  also  enter 
the  larynx,  wdiere  it  may  possibly  initiate  those  inflam- 
matory changes  in  the  mucous  membrane  of  the  air- 
passages  wdiich  are  too  frequently  the  harbinger  of  death 
in  this  disease.'' ' 

Still,  if  carefully  and  properly  used,  nitrate  of  silver, 
in  many  cases,  is  undoubtedly  of  benefit.  If  in  solution, 
it  is  to  be  applied  by  means  of  a  probaug  or  brush, 
swabbing  over  the  diseased  surface  quickly,  at  the  same 
time  thoroughly.  The  strength  of  the  solution  should 
be  from  30  to  60  grains,  and  perhaps  higher,  to  the 
ounce  of  water,  according  to  circumstances.     For  chil- 

•  Observations,  &c.,  by  F.  A.  Bulley,  F.  R.  C.  S.,  Med.  Times  and 
Gaz.,  April,  1859. 


112  DIPHTHERIA. 

clren,  a  full-sized  camel's-liair  brush  is  best.  The  clnld 
should  be  placed  on  the  lap  of  an  attendant,  and  the 
head  firmly  fixed.  If  he  will  not  open  the  mouth,  the 
nostrils  should  be  closed  for  a  few  moments,  and  as  he 
opens  the  mouth  for  breath,  the  jaw  should  be  at  once 
depressed,  and  then,  the  tongue  being  kept  down  by  the 
finger,  the  fauces  are  brought  well  into  view,  and  the 
solution  thus  thoroughly  applied.  The  utmost  gentle- 
ness and  patience  should  be  exercised ;  but  at  the  same 
time,  it  should  be  done  with  firmness,  for  upon  the 
effectual  accomplishment  of  this  proceeding  the  success 
of  the  treatment  will  greatly  depend.  This  should  be 
repeated  every  three  or  four  hours,  so  long  as  it  is 
necessary. 

The  nitrate  of  silver  may  also  be  employed  in  the 
solid  form,  but  this  we  should  not  advise,  particularly 
in  the  case  of  children.  During  the  struggles  of  the 
little  patient  the  crayon  might  become  broken,  an  acci- 
dent which  has  happened,  and  fragments  fall  into  tlie 
oesophagus  or  larynx,  giving  rise  to  serious  lesions. 
Moreover,  the  nitrate  of  silver  in  this  form  has  the  dis- 
advantage of  creating  a  more  decided  eschar  than  the 
solution,  simulating  the  diphtheritic  exudation,  and  thus 
hindering  the  perception  of  the  progress  of  the  disease. 

The  tinct.  fcrri  chloridi  is  an  excellent  substitute  for 
the  nitrate  of  silver,  and  is  now  generally  preferred  by  a 
great  majority  of  practitioners  both  in  this  country  and 
in  Europe.     This  may  be  applied  by  means  of  a  brush 


TREATMENT.  143 

or  sponge,  or  in  a  gargle  of  the  strength  of  two  drachms 
to  eight  ounces  of  water. 

The  hydrochloric  acid  may  be  useful  in  some  cases, 
and  has  also  been  extensively  advocated.  It  is  to  be 
applied  in  a  similar  manner  to  the  other  substances  of 
which  we  have  spoken.  In  the  case  of  children,  the 
addition  of  honey  to  the  acid  is  desirable.  This  is  a 
favorite  topical  remedy  of  M.  Bretonneau.     He  says: — ^ 

"At  the  commencement  of  the  epidemic  at  Tours, 
topical  remedies  suggested  themselves.  The  beneficial 
effects  of  hydrochloric  acid  soon  gained  for  it  an  exclu- 
sive preference.  In  the  use  of  this  acid,  it  is  preferable 
to  employ  it  in  full  strength,  at  long  intervals,  than  to 
return  to  less  energetic  applications  more  frequently." 

Another  gargle,  which  is  very  ef&cacious,  and  which 
has  also  the  advantage  of  correcting  the  fetor  of  the 
breath  and  the  secretions  of  the  throat,  is  a  solution  of 
the  chloride  of  soda,  in  the  proportion  of  one  drachm  to 
six  ounces.  This  may  either  be  employed  by  itself,  or 
combined  with  other  applications.  The  same  may  be 
said  of  the  chlorate  of  potash.  The  combination  of  chlo- 
rate of  potash  and  hydrochloric  acid  with  the  tincture  of 
the  sesquichloride  of  iron  is  strongly  to  be  recom- 
mended, especially  in  the  croupal  cases,  the  chlorate  of 
potash  having  an  undoubtedly  anti-diphtheritic  influence, 
where  time  permits  it  to  be  brought  into  play. 

Numerous  other  applications  to  the  fauces  have  been 
advocated   and   successfully  employed.     Among   these 

'  Traite  de  la  Diphtherite. 


14i  DIPHTHERIA. 

may  be  mentioned,  strong  solutions  of  sulpliate  of 
copper ;  the  chloride  of  sodium,  either  by  itself  or  com- 
bined with  vinegar ;  gargles  of  tannin,  capsicum,  &c. ; 
Monsell's  salt  in  powder.  Of  this  last  substance.  Dr. 
Beardsley,  in  his  paper  upon  the  epidemic  at  Milford, 
Connecticut,  to  which  we  have  previously  referred, 
writes : — 

'' Monsell's  salt  was  found  to  be  the,  most  efficacious 
and  valuable  of  all  topical  remedies,  affording  in  some 
instances  decided  relief.  Its  active  astringent  property 
rendered  it  peculiarly  appropriate,  and  well  adapted  to 
obviate  that  relaxed  and  enfeebled  condition  of  the 
throat  Avhich  attends  the  advanced  stas^e  of  the  disease." 

In  cases  where  there  is  much  tonsillitis,  we  may  em- 
ploy the  inhalation  of  steam,  mucilaginous  gargles, 
warm  fomentations,  &;c.  These  often  afford  marked 
relief,  and  are  useful  adjuncts  to  the  other  treatment. 

M.  Grand  Boulogne  states  that,  in  the  Havannah, 
during  two  violent  epidemics,  he  met  with  great  success 
in  the  use  of  ice  as  a  remedy.  He  caused  the  patients 
to  keep  it  constantly  in  their  mouths  even  into  convales- 
cence. 

M.  Bouchut^  advises  the  ablation  of  the  tonsils  early 
in  the  disease,  not  only  for  the  purpose  of  removing  the 
exudation  which  appears  on  them,  and  which  he  con- 
siders the  localization  of  the  disease,  but  also  of  facili- 
tating respiration.  Such  a  proceeding  we  should  not 
consider  advisable,  to  say  the  least,  for  the  following  rea- 

'  Gazette  des  Hopitaux,  1858. 


TREATMENT.  145 

sons :  In  tlie  first  place,  the  exudation  is  almost  sure  to 
re-forra  upon  the  cut  surface ;  next,  there  is  a  great  risk 
of  severe  hemorrhage ;  and  finally,  any  cutting  opera- 
tion, however  simple,  had  better  be  avoided,  if  possible, 
especially  upon  young  children,  and  in  a  disease  so 
asthenic  in  its  character. 

The  removal  of  the  tonsils  in  this  disease  might  pos- 
sibly be  practised  upon  an  adult,  when  there  is  great 
tumefaction,  and  for  the  purpose  of  facilitating  respira- 
tion, and  for  this  purpose  only. 

When  the  nasal  fossae  have  become  implicated,  various 
solutions  should  be  injected  through  the  nostrils.  MM. 
Bretonneau  and  Trousseau  recommend  a  solution  of 
alum,  or  the  insufflation  of  the  same  substance  in  powder. 
We  should  advise,  however,  a  solution  of  the  chloride 
of  soda,  in  the  strength  of  two  drachms  to  eight  ounces 
of  water,  to  which  two  ounces  of  glycerine  may  be  added. 
Frequent  injections  of  warm  water  and  soap  may  also  be 
thrown  up,  in  order  to  cleanse  the  parts  and  remove  the 
offensive  odor. 

Kitrate  of  silver,  sulphate  of  zinc,  and,  in  fact,  any 
solution  which  is  applicable  for  the  fauces,  will  answer 
a  good  purpose  for  injecting  the  nasal  foss^. 

But  when  in  spite  of  all  means  of  treatment,  energeti- 
cally and  judiciously  employed,  the  disease  progresses 
steadily  onwards,  and  the  larynx  and  trachea  are  invaded 
by  the  exudation,  giving  rise  to  sj^mptoms  of  imminent 
danger,  then  the  important  question  of  tracheotomy  must 
be  entertained. 
13 


146  DIPHTHERIA. 

Without  going  into  a  history  of  tracheotomy,  or  a 
recapitulation  of  the  arguments  on  the  one  side  or  the 
other,  we  most  unhesitatingly  say  that,  under  the  cir- 
cumstances above  mentioned,  this  operation  is  a  resource 
which  we  are  in  duty  bound  to  afford  our  patient,  and  in 
view  of  what  experience  teaches  us  is  otherwise  certain 
death.  It  is  not  that,  by  so  doing,  we  increase  his 
chances  for  life  solely,  but  in  the  case  of  an  unfavorable 
termination,  we  render  his  last  moments  less  distressing. 

It  has  been  urged  that  the  operation  of  tracheotomy  is 
not  warrantable  in  those  cases  of  croup  which  are  the 
result  of  the  extension  of  the  diphtheritic  exudation  to 
the  larynx,  as  the  patient  not  merely  dies  from  asphyxia, 
but  sinks  likewise  from  a  constitutional  infection ;  on  the 
other  hand,  it  has  been  urged  that  there  is  even  a  better 
chance  of  success  with  the  operation  than  in  true  croup, 
the  membrane  being  less  apt  to  spread  to  the  bronchi. 

For  ourselves,  we  can  see  no  validity  in  any  argu- 
ments which  have  been  adduced  either  in  favor  of  or 
against  tracheotomy  in  diphtheria,  which  would  not  be 
equally  applicable  to  the  same  operation  in  cases  of 
croup,  and  in  this  opinion  we  are  supported  by  statistics. 

"With  a  view  to  a  correct  appreciation  of  the  subject, 
we  would  refer  to  the  remarks  made  by  Dr.  Fuller,  in 
the  course  of  a  paper  read  to  the  Eoyal  Med.-Chirurgical 
Society,  in  1857.  Dr.  Fuller  began  by  referring  to  the 
difference  existing  physiologically  and  pathologically 
between  idiopathic  inflammatory  croup,  and  the  diph- 
thcj'itic  form  of  the  disease  which  commonly  prevails  in 


TBEATMENT.  147 

France,  and  he  pointed  out  that  the  objection  usually 
■urged  against  French  statistics  of  tracheotomy  in  croup, 
viz.,  that  diphtheritic  cases  are  much  more  favorable  for 
the  performance  of  the  operation  than  the  croup  cases 
usually  met  with  in  Great  Britain,  has  no  foundation  in 
fact.  By  reference  to  483  cases  in  which  tracheotomy 
had  been  performed  for  the  relief  of  croup  in  France, 
he  showed  that  the  operation  had  been  eminently  suc- 
cessful in  the  hands  of  French  surgeons,  and  he  reminded 
the  society  that  inasmuch  as  the  condition  of  the  throat 
externally  and  the  nature  of  the  accompanying  fever  in 
diphtheritis  are  by  no  means  favorable  to  the  operation, 
the  success  which  has  attended  it  can  be  explained  away 
only  on  the  supposition  often  put  forward  by  English 
writers,  that  in  France  the  disease  seldom  extends  into 
the  trachea  and  bronchi,  and  is  rarely  accompanied  by 
bronchitis  or  pneumonia.  The  fallacy  of  this  supposi- 
tion was,  however,  shown  by  reference  to  the  recorded 
results  of  the  post-mortem  investigations  of  311  cases  of 
croup  in  France,  and  he  also  showed  that  in  regard  to  its 
pathological  effects,  diphtheritis,  when  accompanied  by 
croupal  symptoms,  does  not,  as  compared  with  inflamma- 
tory croup,  present  any  greater  prospect  of  success  for 
the  operation  than  it  does  in  the  character  of  its 
accompanying  fever,  or  the  condition  of  the  throat 
externally. 

Granting  then  that  the  two  diseases,  inflammatory 
croup  and  diphtheria,  stand  on  an  equal  footing  as 
regards  the  applicability  of  the  operation,  let  us  briefly 


148  PIPnTHERIA. 

consider  a  few  of  tlie  oLjectioiis  wliicli  have  been  brought 
against  tracheotomy. 

It  is  urged  that  the  small  amount  of  success  which  has 
hitherto  attended  the  actual  performance  of  this  opera- 
tion in  croup  renders  it  an  expedient  to  which  it  is 
scarcely  justifiable  to  have  recourse.  If  we  refer  to  the 
statistical  inquiries  of  different  countries^  we  shall  find 
that  this  objection  has  no  foundation.  Thus,  in  France, 
where  in  cases  of  croup  tracheotomy  has  been  resorted  to 
on  an  extended  scale,  although  the  rate  of  mortality  has, 
on  the  whole,  averaged  about  seventy-six  per  cent,  of 
the  cases  operated  upon,  yet  in  about  680  cases  in  which 
the  operation  was  performed,  the  mortality  only 
amounted  to  sixty-eight  per  cent. 

According  to  M.  Andre,  during  the  year  1856,  there 
were  54  operations  of  tracheotomy  for  croup  at  the 
Children's  Hospital  in  Paris.  Out  of  these  there  were 
39  deaths  and  15  recoveries,  or  over  27  per  cent. 

The  proportion  of  recoveries  obtained  by  M.  Guersant 
in  a  very  considerable  number  of  operations  performed 
during  the  last  three  or  four  years  Avas  about  one-third. 

In  a  summary  drawn  up  by  M.  Bouchut,  he  says : — 

"Although  the  success  of  traclieotomy  is  not  very  strik- 
ing, yet  the  results  are  such  as  ought  to  encourage  its 
adoption.  Thus  M.  Bretonneau  performed  the  operation 
in  20  cases,  and  out  of  these  6  were  successful.  In  my 
own  practice,  160  operated  upon,  5  saved.  M.  Velpeau 
saved  2  in  10.     M.  Petit,  6  operated  upon,  of  which  3 


TREATMENT.  149 

were  successful.  Thus,  out  of  176  cases,  we  have  16 
which  terminated  favorably." 

M.  Chaillou,  in  the  Journal  of  Practical  Medicine  and 
Surgery,  gives  the  following  statistics  as  regards  the 
operation  in  cases  of  confirmed  croup.  In  eight  years, 
880  operations  of  tracheotomy  were  performed,  of  which 
86  were  successful,  an  encouraging  result,  when  by  far 
the  greatest  number  of  patients  were  operated  upon  in 
the  last  stages. 

The  statistics  of  tracheotomy  at  the  Hopital  des  Enfans 
in  1855  showed  ten  cures  and  thirty-eight  deaths,  out  of 
forty-eight  cases,  or  one  patient  saved  in  five.  Since  this 
period  the  ratio  has  very  much  improved,  owing  to  a 
more  extended  experience  in  the  mode  of  performing  the 
operation,  and  in  the  necessary  after-treatment. 

In  Great  Britain  the  recorded  results  of  the  operation 
exhibit  a  fair  amount  of  success.  In  22  recorded  cases 
in  1857,  no  less  than  eight  terminated  satisfactorily. 

Dr.  Fuller,  above  cited,  reports  five  cases  of  croup  for 
which  tracheotomy  was  performed,  in  two  of  which  life 
was  saved.  The*  results  of  the  operation  in  England  are, 
however,  for  some  undetermined  cause,  far  less  favorable 
than  those  which  have  been  obtained  in  France  or  in 
this  country. 

The  most  recent  statement  of  the  results  of  trache- 
otomy in  France,  is  that  of  MM.  Eoger  and  See ;'  this 

'  Gazette  HeLiloin.,  Nov.  1858. 
13" 


150  DIPHTHERIA. 

gives  126  recoveries  in  416  operations,  or  27  per  cent, 
during  the  last  seven  years. 

A  mucli  lamer  amount  of  statistics  mi^-ht  be  added  to 
those  which  we  have  brought  forward,  but  sufficient  has 
been  offered  to  prove  the  propriety  under  certain  circum- 
stances, of  performing  tracheotomy  in  this  disease. 

It  has  been  objected  that  the  operation  was  a  very 
difficult  one,  and  that  in  itself  it  was  very  dangerous. 
In  answer  to  the  first  of  these  objections,  we  will  say 
that,  in  the  case  of  young  children,  it  is  often  a  difficult 
proceeding,  and  requires  a  greater  amount  of  operative 
skill  and  care  than  is  commonly  supposed.  These 
circumstances,  however,  should  scarcely  be  held  to 
militate  against  our  having  recourse  to  the  operation 
wlien  the  necessity  of  the  case  demands  it. 

But  that  tracheotomy  is  in  itself  a  very  dangerous 
operation,  the  tendency  of  the  evidence  on  this  point 
goes  to  disprove.  Thus,  M.  Trousseau^  has  collected  the 
records  of  ninety-six  cases,  in  which  tracheotomy  was 
performed  for  the  removal  of  foreign  bodies  in  the  wind- 
pipe, and  in  seventy-three  of  these  a  complete  cure  was 
effected,  the  rate  of  mortality  after  the  operation  amount- 
ing to  about  twenty-four  per  cent,  of  the  cases  operated 
upon.  This  gentleman  has  himself  performed  tracheot- 
omy in  more  than  200  cases,  with  success  in.  more  than 
a  quarter  of  the  whole  number  of  cases.* 

Dr.  Gross,  in  his  Treatise  on  Foreign  Bodies  in  the  Air- 

'  "  Discussion  at  French  Academy,"  hy  M.  Trousseau. 
*  Brit.  Med.  Journal,   Jan.  18G2. 


TREATMENT.  151 

Passages,  lias  collected  the  particulars  of  176  cases  in 
which  foreign  bodies  had  accidentally  gained  entrance 
into  the  air-passages.  Id  68  of  these,  tracheotomy  was 
performed;  and  the  mortality  reached  only  11  per  cent. 

We  must  take  into  consideration,  when  making  a 
comparison  between  the  results  of  tracheotomy  performed 
for  the  removal  of  foreign  bodies,  and  those  of  this  oper- 
ation for  the  relief  of  croup,  that,  in  the  former  case,  the 
tissues  operated  upon  are  generally  healthy,  whereas,  in 
the  latter  case,  they  are  the  seat  of  certain  morbid 
chano-es.  Yet  not  with  standinsr  this,  there  is  not  suffi- 
cient  danger  in  the  operation  itself,  under  any  circum- 
stances, to  deter  us  from  performing  it. 

Dr.  West,  after  speaking  of  the  more  favorable  results 
of  the  operation  obtained  in  France  than  in  England, 
owing,  as  he  thinks,  to  its  frequent  performance  in  the 
former  country  when  other  means  might  have  been  tried 
which  would  prooably  have  controlled  the  disease, 
says : — 

"  Still,  if  these  facts  detract  something  from  the  appa- 
rent value  of  the  operation,  they  at  least  show  that  in 
itself  it  is  not  attended  by  serious  danger ;  and  recent 
statistics  prove  that,  in  as  far  at  least  as  the  diphtheritic 
form  of  croup  is  concerned,  there  is  no  sort  of  connection 
between  an  increased  frequency  in  the  performance  of 
tracheotomy  and  a  higher  mortality  from  the  disease."^ 

The  gravest  objection  which  is  brought  against  the 
operation,  is,  that  it  is  apt  to  induce  severe  bronchitis,  or 

'  Lectures  on  Diseases  of  Cliildhood,  &c.,  1859. 


152  DIPHTHERIA. 

at  least  to  greatly  aggravate  any  previously  existing 
inflammation  of  the  lungs  or  bronchial  tubes.  In  answer, 
we  say,  that,  although  there  is  some  ground  for  this 
accusation,  on  the  other  hand,  it  must  be  remembered 
that  these  very  inflammatory  conditions  are  the  almost 
invariable  complications  of  croup,  however  treated,  and 
that  they  do  not  ordinarily  follow  tracheotomy  when 
resorted  to  in  other  circumstances,  as  for  the  removal  of 
foreign  bodies,  for  acute  laryngitis,  or  for  oedema  of 
the  glottis. 

Other  objections  have  been  brought  against  the  pro- 
priety of  tracheotomy  in  cases  of  croup  and  diphtheria, 
which  we  could  satisfactorily  answer  did  space  permit. 
AYe  can  only  add,  in  conclusion,  that  there  do  not  appear 
to  be  any  evils  attendant  upon  the  operation  which 
counterpoise  the  indisputable  benefits  to  be  derived 
from  it. 

A  few  words  upon  the  proper  period  for  performing 
the  operation.  Tracheotomy  has  been,  and  is  still  con- 
sidered by  a  great  portion  of  the  profession,  especially 
in  this  country  and  in  Great  Britain,  as  the  very  last 
resort.  Within  the  last  few  years,  however,  the  opinion 
of  those  best  able  to  form  a  judgment  has  materially 
changed.  A  middle  period  should  be  selected  for  the 
operation.  We  should  not  wait  until  the  case  is  des- 
perate, the  patient  in  a  complete  state  of  prostration,  in 
fact  moribund  ;  nor,  on  the  other  hand,  should  we  attempt 
the  operation  too  early,  before  other  remedies  have  been 
fairly  and  completely  tested.     But  we  are  to  resort  to 


TREATMENT.  153 

the  operation  "  so  soon  as  ever  we  feel  that  our  remedies 
are  too  tardy  to  overtake  the  disease." 

There  are  some  circumstances  relating  to  the  proper 
management  of  the  operation  and  to  the  after-treatment, 
which  greatly  influence  the  results  of  tracheotomy,  at 
which  we  must  hastily  glance.  The  first  of  these  con- 
cerns the  size  of  the  tracheal  tube,  the  importance  of 
which  was  first  insisted  upon  by  M.  Trousseau.  This 
gentleman  explains  the  occasional  sudden  and  appa- 
rently causeless  disappearance  of  the  amendment  which 
at  first  follows  the  operation,  by  the  inadequate  size  of 
the  canula,  which  is  frequently  emploj^ed,  and  which 
does  not  provide  for  the  constant  and  permanent  ad- 
mission of  a  sufficient  quantity  of  air.  In  illustration  of 
this  fact,  M.  Trousseau  says : — 

"  Take  a  quill,  and,  closing  your  nostrils,  endeavor  to 
breathe  entirely  through  it ;  at  first  you  breathe  easily 
enough,  but  soon  your  respiration  becomes  laborious, 
and  at  length  you  are  fain  to  throw  away  the  quill,  and 
with  open  mouth  once  more  to  fill  your  lungs  com- 
pletely. Now  precisely  this  is  what  happens  when  an 
opening  of  inadequate  size  is  made  into  the  trachea,  air 
enters  readily,  and  without  the  interruption  which  the 
spasm  of  the  glottis  occasioned ;  but  it  does  not  enter  in 
sufficient  quantity,  and  hence  the  return  of  the  symptoms 
and  the  patient's  death." 

Acting  on  this  principle,  M.  Trousseau  makes  a  larger 
opening  into  the  trachea,  and  introduces  a  larger  canula 


15i  DTPIITIIEPvIA. 

than  was  formerly  used  ;  and  this  practice  is  now  gaining 
ground,  especially  in  the  United  States. 

Dr.  Hillier  says,  in  a  clinical  lecture  on  Diphtheria, 
that  in  order  to  give  the  child  an  opportunity  of  cough- 
ing and  clearing  the  tubes  of  mucus  and  other  matters, 
the  tube  may  be  closed  for  two  or  three  seconds  by  the 
finger.  AYhen  the  finger  is  removed  a  deep  inspiration 
is  taken,  then  the  tube  is  closed  again  until  an  effort  to 
cough  is  made,  then  the  finger  is  suddenly  taken  away 
and  the  offending  materials  are  expelled.  Use  a  good 
sized  double  tracheal  tube.' 

Another  necessary  precaution  has  reference  to  the  ne- 
cessit}^  of  insuring  to  the  patient,  after  the  operation,  a 
warm  moist  atmosphere,  which  may  be  easily  effected  by 
filling  the  room  with  steam  from  some  simple  apparatus ; 
and  to  keeping  the  room  at  a  fixed  temperature,  and, 
though  well  ventilated,  free  from  all  draughts.  The  neck 
also  should  be  surrounded  with  several  folds  of  muslin,  so 
as  to  cover  the  orifice  of  the  tube.  Great  care  should  also 
be  taken  to  keep  the  canula  free,  and  as  upon  this  one  thing 
the  whole  result  of  the  operation  may  depend,  it  should 
not  be  intrusted  to  unskilful  hands,  but  to  a  medical 
student,  or  to  some  competent  person,  upon  whom  full 
reliance  can  be  placed.  This  is  a  point  which  has  not 
attracted  the  attention  which  it  deserves,  for  not  unfre- 
quently  cases  occur  where  death  suddenly  takes  place 
from  the  stoppage  of  the  tube,  the  persons  in  charge 
fearinnf  to  do  what  the  occasion  of  the  moment  demands. 

o 

1  Med.  Times  and  Gazette,  April,  18G2. 


TREATMENT.  155 

Medical  treatment  must  not  be  suspended  after  t"he 
operation.  The  same  measures  wMcli  were  considered 
useful  before  the  operation  must  be  steadily  persevered 
in.  Great  stress  has  been  laid  by  a  few  writers  in  our 
country  upon  the  importance  of  throwing  nitrate  of  silver 
injections  into  the  trachea.  These  we  certainly  advocate, 
as  cases  have  come  under  our  observation  where  very 
beneficial  results  have  followed  their  employment. 

The  period  at  which  the  canula  ought  to  be  removed 
is  also  an  important  point,  on  account  of  the  irritation  of 
the  edges  of  the  wound  which  its  long  continued 
presence  is  apt  to  produce.  M.  Andre,  in  his  statistics 
before  alluded  to,  has  endeavored  to  ascertain  the  proper 
period  for  this  purpose.  His  observations  were  made  in 
17  cases.  In  1  it  Avas  taken  out  on  the  fourth  day ;  in  5 
on  the  sixth  day;  in  2  on  the  seventh;  in  3  on  the  eighth; 
in  1  on  the  eleventh ;  1  on  the  thirteenth ;  1  on  the  four- 
teenth, and  1  after  the  fourteenth.  From  the  fourth  to 
the  fifth  day  is  the  time  recommended  by  M.  Andre. 
After  the  removal  of  the  canula  the  wound  is  to  be 
covered  with  a  bit  of  gauze,  the  edges  touched  daily 
with  the  nitrate  of  silver,  and  dressed  with  a  little  sper- 
maceti or  other  ointment.  The  tube  is  to  be  replaced  if 
dyspnoea  recur. 

In  addition  to  what  has  been  already  said  on  the  treat- 
ment of  diphtheria,  it  may  not  be  inappropriate  to  give 
a  summary  of  the  treatment  recommended  by  some  of 
the  principal  practitioners  of  Europe. 

Mr.  Ranking,  in    his  lectures  on  diphtheria  {Lancet, 


156  DIPHTHERIA. 

January,  1859),  recommends  the  tinct.  ferri  chloridi,  10 
to  15  drops  every  three  or  four  hours,  and  the  same  to 
be  applied  locally ;  the  diet  to  be  nourishing. 

Mr.  Hart,  of  the  '^Lancet  Sanitary  Committee,"  advises 
a  tonic  treatment,  tinct.  ferri  chloridi,  chlorate  of  potasli, 
(fee. ;  and  as  local  treatment,  the  nitrate  of  silver,  30  to  60 
grs.  to  the  ounce,  or  the  muriatic  acid. 

Dr.  Kingsford  {Lancet,  Nov.  1858),  in  simple  diphthe- 
ria, uses  a  calomel  purge  in  the  commencement.  Then 
chlorate  of  potash,  with  dilute  hydrochloric  acid  in  a 
decoction  of  bark,  and  mopping  the  throat  two  or  three, 
times  a  day  with  the  compound  solution  of  alum.  In  the 
severe  forms  he  uses  wine  and  nutritious  diet  freely,  and 
gives  tinct.  ferri  chloridi,  with  chlorate  of  potash,  10  to 
30  drops  of  the  former  with  10  to  30  grs.  of  the  latter, 
every  two  or  three  hours,  according  to  circumstances. 
Nitrate  of  silver  to  the  throat — wine  and  nutritious  diet 
freely.  If  much  difficulty  of  deglutition,  enemata  of 
strong  beef-tea,  and  port-wine  every  two  hours,  the 
quantity  to  be  injected  not  to  exceed  two  or  three  ounces 
at  a  time.  Mercury  he  thinks  contraindicated,  except  as 
a  cachectic  at  the  beginning. 

Dr.  Perry,  of  Kent  {Med.  Times  and  Gaz.,  March,  1859), 
gives  oil  of  turpentine,  ten  drops  every  second  hour,  to  a 
child  of  from  two  to  six  years  of  age,  and  alternates  this 
with  five  grains  of  carbonate  of  ammonia  every  two 
hours.  Besides  this,  port-wine,  porter,  and  beef-tea,  or 
wine  with  the  velk  of  an  ei2-<r,  ad  llhltum.  He  thinks 
tliut  mercury  hastens  tlie  fatal  result. 


TREATMENT.  157 

Dr.  Cammack  {Lancet,  Oct.  1858)  gives  a  calomel  pur- 
gative where  symptoms  of  laryngitis  appear,  and  a  decoc- 
tion of  cinchona  with  hydrochloric  acid.  A  gargle  of 
salt  and  vinegar  for  the  mouth  and  throat,  which  he  also 
injects  up  the  nostrils  when  they  become  affected.  He 
applies  the  solid  nitrate  of  silver  to  the  exudation.  He 
is  convinced  that  the  malady  is  herpetic. 

The  editor  of  the  Lancet  (October,  1858)  thinks  the 
disease  is  not  a  new  one,  but  believes  it  to  be  a  form  of 
scarlet  fever.  He  gives  ammonia  and  beef-tea  early,  and 
keeps  the  skin  softened  by  the  steamed  blanket.  A 
warm  blanket  wrung  from  hot  water  is  to  be  put  around 
the  patient,  this  to  be  enveloped  in  dry  blankets,  and  the 
patient  to  be  sweated  for  an  hour  and  rubbed  rapidly 
dry,  and  again  covered  with  dry  blankets.  ''  Keep  him 
up  with  ammonia  and  good  nutritious  broths." 

Mr.  Thompson  {Brit.  Med.  Journal,  June,  1858)  advises 
thorough  applications  of  nitrate  of  silver  to  the  throat, 
a  stimulating  gargle  of  nitrate  of  potash,  and  capsicum, 
or  solution  of  chlorinated  soda.  Mild  but  continued 
counter-irritation  over  the  upper  part  of  the  chest  ap- 
peared of  great  service.  General  treatment  he  thinks  of 
little  use.  Stimulants  are  often  required  in  the  early 
stage. 

M.  Roche  {L  Union  Medicate,  July  26,  1^59)  places 
great  reliance  on  the  following  treatment.  Having  first 
freely  cauterized  the  false  membrane  with  lunar  caustic, 
he  injects  every  hour  against  the  fauces  a  solution  of 
common  salt,  not  of  sufficient  strength  to  create  nausea. 
14 


158  DIPHTHERIA. 

The  tincture  of  iodine  he  also  employs  as  a  topical  appli- 
cation. 

Mr.  Ramskill  {Lancet,  February,  1859)  makes  use  of  an 
infusion  of  chamomile  to  wash  and  syringe  out\  the 
throat  and  nares  of  children,  to  which  he  adds  a  few 
drops  of  creasote,  or  of  the  liquor  calcis  chlorinate. 
Internally  he  gives  chamomile  with  muriatic  acid  and 
ether  and  quinine^  at  the  same  time  good  nourishment 
and  stimulants. 

Dr.  West,  in  his  Treatise  on  Diseases  of  Childhood, 
adopts  the  following  mode  of  treatment.  A  drachm  of 
the  nitrate  of  silver  to  the  ounce  of  water  is  applied  to 
the  throat  either  by  means  of  brush  or  probang;  if 
necessary,  afterwards  the  strong  hydrochloric  acid,  di- 
luted with  from  four  to  ten  parts  of  honey.  One,  or  at 
the  most,  two  applications  of  the  stronger  caustics  in  the 
twenty-four  hours  suffice.  These  are  preferable  to  the 
weaker  ones,  as  these  latter  must  be  applied  frequently, 
which  distresses  the  child.  For  this  reason  he  does  not 
make  use  of  the  tincture  of  iron,  nor  does  he  employ 
insufflations  of  powdered  alum  or  calomel.  The  mouth 
may  be  kept  free  from  the  secretions  which  are  apt  to 
accumulate  in  it  by  syringing  it  every  three  or  four 
hours,  with  a  lotion  of  the  chloride  of  soda,  half  au  ounce 
to  six  ounces  of  vratcr.  As  constitutional  treatment,  he 
advises  quinine  with  the  tincture  of  bark  and  hydro- 
chloric acid,  at  short  intervals.  The  best  of  nourishment 
and  stimulants. 

Dr.  Semple  (Lancet,  October,  1858")  says  that  the  best 


TREATMENT.  159 

treatment  is  the  application  of  strong  caustics,  of  which 
the  concentrated  hydrochloric  is  the  best,  at  the  very 
earliest  possible  period.     Nourishing  diet,  &c. 

M.  Enipis  {Arch.  Gtn.  de  Medecine)  advocates  the  use 
of  local  remedies,  such  as  the  hydrochloric  acid  and  the 
nitrate  of  silver,  and  for  constitutional  treatment,  tonics 
and  nutritious  food.  In  these  views  M.  Isambert  also 
concurs. 

In  our  own  country,  during  the  epidemic  which  pre- 
vailed at  Albany  in  1858,  gargles  containing  chlorates  of 
potash  and  soda,  or  vinegar  with  the  mineral  acids  and 
tonics  internally,  constituted  the  principal  treatment. 
During  the  epidemics  at  San  Francisco,  very  much  the 
same  treatment  was  pursued.     So  also  in  Connecticut. 

Prof.  Chapman,  of  New  York,  in  a  series  of  excellent 
papers  upon  this  disease,  advocates  the  adoption  of  a 
stimulating  treatment.  He  gives  the  history  of  thirty- 
eight  cases  in  which  the  disease  is  presented  in  almost 
every  varied  phase.  He  says:  ''Of  the  remedies  that 
have  been  employed  in  diphtheria,  two  only  have  proved 
themselves  in  our  hands  worthy  of  confidence,  wdth  the 
exception,  in  the  chronic  stage,  in  favor  of  the  salts  of 
iron.  These  two  remedies — alcohol  or  cinchona  in  one 
of  its  forms — are  administered  in  such  doses  and  at  such 
intervals  as  to  secure  one  effect — the  fullest  stimulation 
of  the  nervous  and  vascular  systems.  Either  singly  may 
suffice  when  the  vital  force  needs  but  slight  aid  to  main- 
tain the  integrity  of  the  blood ;  but  the  two  united  have 
more  than  a  double  power,  and  call  out  the  greatest 


160  DIPHTHERIA. 

possible  amount  of  resistance,  since  the  nerve  centres 
and  bloodvessels^  the  great  life-factors,  are  exalted  to  the 
highest  point;  although  liquors,  when  given  in  such 
quantities  and  intervals  as  to  occasion  and  keep^  up  a 
steady,  but  not  excessive  excitation,  not  only  quicken  the 
functional  offices  of  each  organ,  but  act  more  especially 
on  the  nervous  and  vascular  systems. 

"It  is  a  noteworthy  fact  that,  in  my  experi- 
ence, the  diphtheria  never  attacks  those  habituated  to  the 
use  of  spirits.     This,  if  confirmed,  may  be  more  than  a 

remarkable  coincidence Both  the  cinchona  and 

the  alcoholic  stimulant,  whether  used  singly  or  united, 
should  be  given  with  regularity  and  in  sufficient  doses  to 
obtain  their  full  effects ;  and  then  the  latter,  in  a  lessened 
quantity,  continued  for  two  or  more  weeks  after  the 
disappearance  of  the  disease  and  its  sequelas.  From  the 
outset  to  a  permanent  restoration  to  health,  one  or 
perhaps  both  of  these  remedies  are  to  be  continuously 
administered.'" 

Although  there  is  some  diversity  in  the  treatment  of 
diphtheria,  as  laid  down  by  different  authorities,  still,  it 
will  be  seen  that  the  affection  is  considered  by  all  as  one 
decidedly  adynamic  in  its  character,  and  tliat  conse- 
quently a  supporting  treatment  is  necessary,  and  all 
depletory  measures  are  to  be  strictly  avoided.  Authori- 
ties are  also  united  upon  the  necessity  of  a  more  or  less 

'  Practical  Observations  on  and  the  Treatment  of  Diphtlieria.  By 
E.  N.  Chapman.     Boston  Med.. and  Surg.  Journah  Feb.  18113. 


TREATMENT.  161 

enei'getic  local  treatment,  particularly  in  the  early  stages 
of  the  disease. 

Before  closing  our  remarks  upon  the  treatment  of 
diphtheria;  we  must  say  a  few  words  upon  tubing  of  the 
glottis. 

The  unquestionable  efficacy  of  tracheotomy  under 
certain  circumstances  suggested  the  idea  of  inserting  into 
the  larynx  through  the  mouth  an  instrument  which 
might  replace  the  canula  of  tracheotomy  and  render 
unnecessary  the  use  of  the  knife.  Although  others  had 
tried  the  experiment,  M.  Bouchut  was  the  first  who  put 
it  to  practical  use. 

The  operation  consists  in  inserting  into  the  larynx  a 
metallic  tube,  which  is  to  be  retained  for  a  longer  or 
shorter  time  according  to  circumstances. 

The  instruments  used  are:  1.  Curved  male  catheters 
of  different  sizes,  open  at  both  ends,  and  intended  to 
penetrate  into  the  larynx  (C,  C).  2.  Straight  cylindrical 
silver  rings  {A)  of  from  J  to  |  of  an  inch  long,  provided 
at  their  extremities  with  two  ridges  at  the  distance  of  a 
quarter  of  an  inch  and  pierced  with  a  hole  for  the  pas- 
sage of  a  silk  thread  {B),  the  function  of  which  is  to  pre- 
serve a  hold  upon  the  ring  from  without.  8.  A  ring 
{D)  to  protect  the  forefinger. 

The  process  is  quite  a  recent  one,  and  has  not  as  yet 
been  attended  with  any  very  great  success.  Bouchut  re- 
ports seven  cases,  five  of  which  terminated  fatally,  and 
the  other  two  underwent  tracheotomy.  At  a  meeting  of 
the  French  Academy  of  Medicine,  a  committee  was  ap- 

14* 


162 


DIPHTHERIA. 


pointed  to  examine  M.  Boucliut's  communication  on  the 
subject;   of  this  committee  M.  Trousseau  was  appointed 


Fig.  3. 


chairman.  The  report,  which  is  of  some  length,  con- 
cludes with  the  following  resolutions : — 

"1.  Tubing  the  larynx,  in  certain  forms  of  acute 
laryngitis,  may,  by  delaying  asphyxia,  become  a  remedial 
agent. 

"2.    In  certain  chronic  affections  of  the  same  organ, 


KESUME.  163 

tu"5ing  may  permit  traclieotomy  to  be  postponed,  and 
may  occasionally  give  time  to  treat  and  cure  the  disease. 

"3.  In  the  treatment  of  croup,  tubing  retards  asphyxia, 
and  affords  a  more  easy  mode  of  introduction  into  the  air- 
passages  of  remedies  calculated  to  modify  diphtheritic 
inflammation. 

"4:.  It  cannot,  however,  supply  the  place  of  trache- 
otomy, which  to  this  day  remains  the  only  expedient  in 
croup,  when  the  resources  of  medicine  seem  to  have  been 
exhausted." 

RESUME. 

In  the  preceding  pages,  we  first  gave  Bretonneau's 
description  of  diphtheria.  We  then  remarked  that  it 
was  only  by  a  comparison  of  the  various  epidemics  of 
"sore  throat"  Avhich  had  prevailed  at  intervals  in  various 
parts  of  the  world,  that  w^e  could  ascertain  how  far  his 
description  was  to  be  taken  as  a  model  of  the  disease. 
Accordingly  we  took  up  the  history  of  the  epidemics 
from  remote  ages  to  the  present  day. 

Having  given  an  account  of  those  which  had  prevailed 
in  various  parts  of  Europe,  and  having  compared  the 
descriptions  of  various  writers  upon  these  epidemics, 
with  that  of  Bretonneau,  we  showed  that  he  was  incorrect 
in  denying  the  presence  of  all  constitutional  disturbance, 
as  also  in  insisting  upon  the  absence  of  all  relation  be- 
tween diphtheria  and  gangrene  of  the  fauces — both  of 
these  conditions  having  been  frequently  observed,  par- 
ticularly during  the  epidemics  of  late  years. 


16i  DIPHTHEEIA. 

We  next  observed  that  Bretouneau's  idea  of  croup, 
which  he  associates  with  diphtheria,  does  not  conform  to 
our  ideas  of  that  disease,  founded,  as  they  are,  upon  the 
description  given  by  Dr.  Home.  The  distinctions  be- 
tween diphtheria  and  croup  were  dwelt  upon,  as  also  the 
non-identity  of  diphtheria  and  scarlatina. 

In  order,  we  took  up  the  history  of  the  disease  in 
England.  A  comparison  of  the  descriptions  of  the  dis- 
ease by  various  writers,  as  it  appeared  in  the  several 
counties,  gave  no  marked  uniformity,  and  but  little  cor- 
respondence with  Bretouneau's  model. 

Diphtheria  in  America  was  then  considered,  and  we 
gave  at  some  length  a  description  of  an  epidemic  of  "sore 
throat,"  by  Dr.  Bard,  also  an  account  of  the  epidemics  in 
California  and  other  parts  of  the  Union. 

We  next  remarked  that  all  these  epidemics  of  '^sore 
throat"  were  connected  by  a  bond  of  union,  to  be  found  in 
the  pathological  anatomy  of  the  disease,  which  consists  in 
the  peculiar  exudation.  That  although  Bretonneau  fully 
recognized  this  fact,  his  description  was  deficient,  hence 
we  subjoined  that  of  MM.  Barthez  and  Rilliet,  as  being 
more  comprehensive.  We  also  considered  the  disease 
as  existing  under  two  forms,  the  mild  and  severe. 

Certain  points  as  respects  the  nature  of  the  disease 
were  taken  up  in  order.  First,  the  characteristics  of  the 
false  membrane,  its  physical  appearances,  its  seat,  the  ex- 
periments of  Bretonneau  in  order  to  ascertain  the  specific 
nature  of  the  diphtheritic  membrane,  its  microscopic  ap- 


RESUME.  165 

pearances,   and  its   dependence   upon   certain    parasites 
were  discussed. 

Next,  in  answer  to  the  question,  Is  diphtheria  infec- 
tious ?  Having^  o-iven  the  aro^uments  of  various  authors, 
we  replied,  that  although  we  were  ignorant  of  the  exact 
laws  which  governed  these  epidemics,  we  are  able  to  de- 
tect certain  hygienic  or  individual  circumstances  which 
undoubtedly  had  their  effect,  either  as  direct  or  as  pre- 
disposing causes. 

The  presence  of  albumen  in  the  urine  and  its  significa- 
tion were  commented  upon.  We  remarked  that  further 
observation  was  necessary  before  we  could  ascribe  to  it 
any  settled  prognostic  value.  We  spoke  of  the  singular 
after-effects  of  the  disease,  as  shown  especially  upon  the 
nervous  system.  We  gave  the  observations  of  MM. 
Trousseau,  Faure,  and  others  upon  this  point. 

In  our  account  of  the  treatment  of  diphtheria,  we  said 
that  it  was  only  within  the  last  few  years  that  anything 
lik#  unanimity  had  prevailed.  That  it  was  now  univer- 
sally regarded  as  an  asthenic  disease,  and  consequently 
would  bear  no  depletory  measures,  but,  on  the  contrary, 
required  tonics,  stimulants,  and  a  nourishing  diet,  even 
in  the  early  stages.  Blisters,  leeches,  and  local  bleeding 
of  any  sort  should  be  prohibited. 

The  tonics  best  suited  we  enumerated.  Of  the  auxil- 
iary measures,  we  first  spoke  of  the  local  applications  to 
the  fauces,  their  utility  and  propriety,  the  various  agents 
which  had  been  employed  and  the  mode  of  use.  The 
ablation  of  the  tonsils  recommended  by  Bouchut,  we  con- 


166  DIPHTHERIA. 

ceived  to  be  inadmissible;  excepting  under  rare  circum- 
stances. 

Tracheotomy  we  discussed  at  considerable  length. 
Eemarking  that  the  two  diseases,  inflammatory  croup 
and  diphtheria,  were  on  an  equal  footing  as  regards  the 
applicability  of  the  operation,  we  answered  the  various 
objections  which  had  been  brought  against  it;  the  small 
amount  of  success ;  the  difficulties  of  performing  it ;  the 
tendency  to  the  production  of  bronchitis,  &c. 

We  considered  that  the  proper  time  for  performing 
the  operation  was  an  intermediate  period.  We  gave  some 
necessary  rules  as  to  the  size  of  the  canula,  the  state  of 
the  surrounding  atmosphere,  the  importance  of  having 
some  competent  person  at  hand  in  the  case  of  emergency, 
the  propriety  of  keeping  up  the  medical  treatment,  and 
the  time  for  removing  the  canula. 

Having  given  a  summary  of  the  treatment  recom- 
mended by  some  of  the  leading  men  in  Europe,  we 
concluded  by  a  brief  consideration  of  the  operation  for 
"tubing  the  larynx." 


FOURTEEN  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

Mlologf  Lnfeirairj 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 

Renewed  books  are  subject  to  immediate  recall. 

N€V    61955 

NOV  2     1955 

tBY3l;J??r,l'-            --IB"'^"'^ 

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